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THE
STUDY  OF  MEDICINE,
JOHN MASON GOOD, M.D. F.R.S.
   MEM. AM. PHIL. SOC. AND K.L.S. OF PHILADELPHIA.
IN FOUR VOLUMES.
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VOL. II.
       BOSTONS
WELLS AND LILLY—CtHJRT-STREET.

         1823. 
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CLASS III.
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           CLASS III.





       H.EMATICA.




  DISEASES OF THE SANGUINEOUS FUNCTION.




ORDER I.



           PYRECTICA.



               FEVERS.




         II.



           PHJ.OGOTICA.



                INFLAMMATIONS.




         III.



           EXANTHEMATICA.



                ERUPTIVE FEVERS.




         IV.



           DYSTHETICA.



               r CACHEXIES.

















                # 
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 to 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 thr 
6                 PHYSIOLOGICAL PROEM.              [CL- nI'
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  Picture
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 the 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 exhalant  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 atenuate 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 6ystem, 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 Physiologic, Tom. n. 
CL. III.]            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 ex-
haled 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
purpose, 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 is^ue  from the heart.  Here,  there- 
8                  PHYSIOLOGICAL  PROEM.            [CL* llh

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
bending of 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.   The}' 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 that 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 Berzeiius, 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 aione ; 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- 
CL. HI.]
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 angles 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. John Hunter on
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 at 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.                                     t
   This vacuity of the arteries upon death, was one of the objections
urged very forcibly by the ancients against the circulation of the
blood, or even its following at all the  course of the arteries ;  and
       # On Blood, Inflammation, &c. Part i. Sect. viii. p. 170.
VOL.  II.              2 
10
PHYSIOLOGICAL PROEM.
[CL. III.
 which  Dr. Harvey  very unsatisfactorily replied to,  by asserting,
 contrary indeed to fact, 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 larger 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 th it which flows from it.   It is not, however, at
 any  lima  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 absurdity  of several of them.  Muller and Abeildgaard
 estimate the weight  even in an adult  at very little more than  eight
 pounds 4 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 'J,On the Vacuity of the Arteries after Death."  Medico-Chir
Trans. Vol. xi. Part i.
  t See Hunter on'Blood, p. 133.
  | Blumenb. Elem. Phys. p. 4. i 6.
  J Phil. Trans. 1809. p. 5. 
CL. III.]
PHYSIOLOGICAL PROEM.
11
weight of the body.   Yet little reliance  can  be placed on this last
mole 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 301b. 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 e timate.
  II. There is another question which has also, in all ages, greatly
occupied  the attention  of physiologists, but  upon wh^ch 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.
   I he  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.*
   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 dependent 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:
" The  alternate contraction and relaxation of the heart  constitutes a
part of the circulation ; and the whole takes place in consequence of
a necessity, 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 momeut one is finished  an
* Hunter on Blood, p. 148. 
12               PHYSIOLOGICAL PROEM.               [cL. in-

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
because 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 consists 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,  vvould stimulate the
heart, there  can  be no doubt, from numerous  experiments which
prove  that a very small 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.t   But, unforiunately  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
and cogent, to prove that no oxygene whatever is introduced into
the bjood in 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
primum  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.
 t De Chirurgia Infusiroa renovauda.  Aut. J. M. Regnaudot. 8vo. Lugd. Bat,
1779. 
CL. III.]
PHYSIOLOGICAL PROEM.
13
Harvey replied to this question by asserting,  that it is maintained
by the action of the heart alone, which 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 to 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 Cheselden, 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 less 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
successively 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 Physiologie. Tom. 11. 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
obstruction, during the systole than  during the diastole  of the heart.
  It may be still further observed,  that, in 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 seats of pulsation
taking place at such different parts at one and  the same time, 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  ac'ion of the arteries and veins
  * Experimental Inqui.y into the Nature, Cause,  and Varieties of the Arterial
Pulse, Aic. By C. H. Puny, M. D. F. R. S. &c.  Bath 1816. 
BL. III.]
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 ascent 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
 ha*e no such organ; and what constitutes  the projectile power in
animals that  have no heart, and  consequently no double pump to
 work with.
* On Blood, p. 187. 
  16                PHYSIOLOGICAL PROEM.             [CL« nI«

   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 and the
 stomach, the former  of which  has  been  proved  by Sir  Everard
 Home  to  receive  fluids  from the  cardiac portion  of the latter,
 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,t 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
 oody, but directly by that of the heart, or of 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 pu.se 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 Lie.  In the man of a high sanguine character it rarely sinks
ttWri 5  $     " °ften Ht ninet* ;  and ia the  melancholic it sel-
dom rises above sixty, and sometimes  sinks to forty.  In idiosyn-

          * Phil. Trans. 1811, p. 16a.
          t Ibid. p. 96. 
CL. III.]
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, Tiid  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 beats
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  of 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 eight 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 .J In  advanced age, fronvthe 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. 2C5.
        t Medic. Trans. Vol. n. Art. n. p. 29.
        t Med. Trans. Vol.n. Art. n. p. 29.
VOi.  II.              3 
18
PHYSIOLOGICAL PROEM.
[CL. III.
  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 aiso attend to its  degree of fuiness, 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 Mutationc quadam pulsus insigni.  Erlang. 1778.  V. Bald. Syll. v. 
CL. III.]
PHYSIOLOGICAL  PROEM
19
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 : u  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
o&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 veii'
high merit too,  whose fingers are no more capable of catching tm>
finer distinctions o 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."!
  Dr. Fordyce's table of  the pulse  is, perhaps, unnecessarily compli-
cated ; but the strength or weakness, fullness 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. u. p. 20.
tOn Blood, Part. n.  Ch. iii. p. 318. 
 20                 PHYSIOLOGICAL  PROEM.            [CL« 1U'

 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 preceding signs, and show, in characters nearly as decisive,
 the degree  of vigour or debility of the heart; and hereby,  except
 where this organ is labouring under some local affection, the vigour
 or debility of the system, which a mere variation in the state of the
 frequency of the pulse will not  tell us.   A full a id 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 I mistake not, it gives us rather a measure of the quantity of
 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
 ™ery 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,! 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,  for applying the doctrine of pulsation as an index to the  dis-
eases  of  every distinct organ  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 Differentia Pulsus ceteris et frequentis.
  t .Novae Observations circa crisium praedictiones ex pulsu.  Wetsch, Medicine
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-
 rate," 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
             S'nsum auimi ceria. nou esse in parte locatum;
             Verura habitum quemdam vitalem corporis esse,
             'apmoniajt 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 publica-
 tions, intitled, " Recherches sur le  Pouls  par rapport aux  crises."!
 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 pulses 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, pursuing 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 ihorough-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. in. 90.  See the author's examination of this hypothesis,
and its resemblance to others of later date, in the notes to his Translation of Lu-
cretius. Book V. 100 and 104.
t Paris 1756, 8vo. 
0
22       \        PHYSIOLOGICAL  PROEM.            [CL* rtl*

   Forthj^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:—1. 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,! and Professor Berzelius,J 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.
Brezelius,  u 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, 1 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 analysis of the blood, as cor-
rected by the later experiments of M. Berzelius, supported by those
I have just adverted to, of Dr. Marcet and Dr. Bostock. •
* Trans. Medico-Chirurg. Soc. Vol. n. p. 370.
  t Id. Vol. i.             |Id. Vol. in. 
CL. III.]
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 3^ 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 decom-
posed, but does not contain, earthy phosphates and carbonate of lime ;
for the entire  blood holds  in solution no earthy phosphate, except,
perhaps, in  too small a quantity to be detected.
  From these earths it is clear that 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, inconsequence 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 upon 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,  about T}^ 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 nolime-stone whatever, and others
* Ann. de Chhn. et de  Phys. V. 42. 
24
PHYSIOLOGICAL PROEM.
[CL. III.
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 cohtains 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 ihe 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 aud
repair of the system.!
  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 seem to have been accompanied with ven
great success.  Delia Torre, by applying his microscope,  detected

       * Phil. Trans. 1812 n. 112.      t On Blood, p. 46.  •". 
CL. 171.]
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  5^Vff part
of an inch; a dimension,  however, which  has since  been reduced
by Captain Kater to ToVo~ Par* °^ 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 phaeoomena 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.!
  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. III.
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
or 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, phthsis ;
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 1 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 had 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-
troling 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.  lt 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."!
  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.          t Phil. Trans. 1815, p. 445. 
CLASS III.
HiEMATlCA,
                          ORDER I.


                      PYRECTICA.



*  SEAT AND NUMBER OF THE  PULSE PRETERNATURALLY AUGMENTED :  USU-
    ALLY  PRECEDED BY RIGOR, AND FOLLOWED BY PERSPIRATION:  OURING
    THE RIGOR,  PAINS FIXED OR  WANDERING : LASSITUDE :  DEBILITY 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, 1 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                       HJEMATICA.            [CL. IH.~OR. I«

 oppression is removed.   Thus, in the yellow fever of Antigua in
 1816,  the pulse, as Dr. Musgrave infoms 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  augmentation as the pulse : for as the former is the result oi
 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 j
 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 nomologists 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 ia the  present place.
  Regulated, therefore, by the principle before us, fever  admits of
 the four following genera :—

       I. EPHEMERA.                    DIARY  FEVER.
      IK ANETUS                       INTERMITTENT FEVER.
     HI.  EPANETUS.                     REMITTENT FEVER.
     IV. ENECIA.                       CONTINUED FEVER.
* Trans. Med. Chir. Soc. Vol. ix. p. 133.      t Lib. vi. Obs. 34. 
CL. IIT.-OR. I.J    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 herely
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 hia
progress in the labyrinth before him.   The  term Ephemera, is,
indeed, well known to every one.   Anetus and Epanetus are Creek
terms, importing intermittent and remittent, from xvir,pt and tirxmy-t.
Enecia, from the same tongue,  denotes  continued  action, and is a
derivation from »)»««»)$.
  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 were its proegumenal or predisponent, and its procat.rc-
tic or occasional.  Thus, an hereditary taint, or habitual indulgence
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 necessary;
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, denomi-
nated an exciting cause.   Generally speaking, the first was regarded
as an internal, and the second as an external  cause ; and in the in-
stance 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 oi' lever.
" 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 epid. mic catarrh.
   In  fever we  can often  trace the remote  causes; though we are 
so
H^MATICA.
[CL. I1I.-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 pkoximate cause as that which has
 most  excited the attention of physicians in all ages.  Upon this sub-
ject,  indeed, a great deal of learned dust has been 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  remain-
der 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.
   HI. 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.
   1. It was the opiiion  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. IH.tOR. I.]     SANGUINEOUS  FUNCTION.                 31

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 is in unison with seve-
ral of the phenomena 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 jj.as 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                       HvEMATICA.           [CL. HI.-OR.  t.
 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.
   II. 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 of 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 superabundance,
press forcibly  into improper  series of vessels, and stagnate in the
extremities of the capillaries whence the  origin ofjlhe cold stao-e
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 hd-
 mectants, and attenuants, whilst those of an opposite  character
 were called inspissants : terms which  have desceuded 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. h. p. 528. Edit. Lugd. Bat. 40. 1745. 
CL. III.-OR. I.]     SANGUINEOUS FUNCTION.
33
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 corpuscu-
lar 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,  rn
the emphatical  language of M. Q,uesnay,  it was  u 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 sponlaneum 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  passive, a mere organic  machine, operated  indeed  upon by
some autocrateia, as  nature, or a vis  medicatrix, 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 preserva-
tion of health where it exists, and  to a restoration of health where
it has been  lost or injurecl.  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.
   von.  n.                   ^ 
34                      HjEMA'IICA.             [CL. IH--OR- '•
 and counteracted by the  remedial exertions of the mind, the v|re9
 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 periphericus :*
 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 historiae intermittentium
 causa proxima constituitur viscositas liquidi arteriosi."  But to this,
in the  edition before  us, is  added  the following: " forte et nervosi
 (liquidi)  tam cerebri, quam  cerebelli cordi destinati, inertia."!
  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
 following passage : " An et naturae humanae facultas inest, moleculas
 acris detritas aut intropressas angulis, 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.1"!  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. m. i  i. cap. 4.  Bochmer, Dis. de Spasmi Peri-
phenci signo m febribus continentibus.  Hal. 1765.
  t De Motii Tonko. 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 oh both subjects, inserted in the Ephemerides Na-
turae Curiosorum, published at Frankfort, in 1684 ; and the writings
of Baglivi,* and  Dr. Willis;! and still more particularly to Dr. Gil-
christ's elaborate treatise on nervous fevers, inserted in the Edin-
burgh  Medical Transactions jj  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  de-
nominates an alternate  nisus and re-nisus.
  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 architecture.  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 or 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 moiboso.
t Pathologia Cerebri ct Nervorum.
t Vol. iv. Art. xxnr. and Vol. v. Part. n. \rt. XT.vm. 
  •*"                       HiEMATICA.            [CL. IH.-OR. 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.  The  force of the heart gives extension
  to the arteries, and the growth of the body depends upon such ex-
  tension  in  conjunction with  the  nutritious  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 enc^phalon ;  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
 altarnately excited  and collapsed, since  every fibrous contraction is
 succeeded by a  relaxation:   whence spasms and convulsions are
 mot* 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.!
 nJ^f ,h7P°hthesis'  jn  **  vari0«s ramifications,  influenced  every
 ETJV  hlsftheory °f medicine, and consequently laid a foundation
 for his doctrine of  fever   The proximate cause of fever was, Z
 his opinion  a collapse or declination of the energy of the  brain pro"
 duced by the application of certain sedative powers,  as con agion
 miasm  cold, and fear,  which constitute  the remote'cau'esThS
 diminished energy extends its influence over the whole system and
 occasions an  universal debility ;  but chiefly over the exTrem^'ves

SpoTedttonlf- S *"" * ^ ta ^ *- thf^oTdfitl
  « Such however," to adopt  the words of Dr. Cullen himself «is

 tctastrihih:oaThTseCODry'that ^  debi'%Pr^fan in-
direct stimulus to the sanguiferous system ; whence by the inter
of thA°/ i G T1? StaffG'  aDd SPaSms ^nected with itf the actfon
of the heart and larger arteries is increased, and continues so »?S




■narks of,he relaxation of *»'£*!%£&*-£$ Md °'he''

          *  Mat. Med. Part n. Chap. vm. 349.
          t  id. Part. ii. Chap. vi. p. 223.
          t  Pract. ofPhy. 4 xtvi. 
CL. III.-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 characteriz-
ed by debility of the iiving 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 pheno-
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 swe^ by which
the hot  stage is succeeded.  But it fails in the two following impor-
tant 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 hanA"
  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 sphool 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
I-LEMAT1CA.
[CL. lll.-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 translator of 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. Cullen 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, are 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 viohjcce of the flame, 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 o/ 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 j  the former produced by ac- 
CL. III.-OR. I.]     SANGUINEOUS FUNCTION.
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
 of various kinds and degrees, the asthenic.
   Fevers, 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 typhus 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 flametis 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
 asthenic 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. III.-OR. 1.

 the  system of Dr. Cullen and  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 w 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  takes 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
* Zoonom. Vol. I. Sect. n. ii. 7. 
CL. III.-OR. I.]
SANGUINEOUS FUNCTION.
41
quietude whatever, and, consequently, no means of re-accumnlating
irritability ; but  one continued train of preternatural action and
exhaustion,  till  the system is completely worn  out.  And to this
objection 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 liscrepant from those now examined have been
offered,  but they have  not acquired sufficient notice,  or evinced
sufficient 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,!  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.
             t Hist. Hepat. p. ll£
             X Pancreas,*&c. p. 141.
             I Briefwechsel, Band. I. p. 150.
             H Treatise on Fever, 8vo.
ro%. n.                  6 
42
ILEMATICA.
[CL. I1I.-0R. fc
 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
 phlogotie divisions of diseages.
   " 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 th^e affection of another paTt."*
   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 before
 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
maintain it, or he must have abandoned  his  system of fever alto-
gether, which supposes it to commence in, and be "primarily depen-
 dant  upon debility.                                     J'   F
   These sedative or debilitating  causes  he reduces to two
MARSH
* On Fever, Dissert, i. p. 28. 
CL. IH.-OR. I.]        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,
v is commonly only an exciting cause concurring with the operation
of human or marsh effluvia.!
   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 littfc 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."J
    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. xcvu.
            t  Id. Sect. xcn.
            ! Nosol. Method. CI. n.  Febr. Theor. Sect. 7?. 
 44                      HiEMATICA.             [CL. III.-OR. h

 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 frftm 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 seasons; climate,
 and other external causes,  or to the peculiar constitutions of the
 individuals affected.   Thus, the miasm of small  pox has uniformly
 continued true to small  pox, and that of measles, to measles; and
 neither of ttiem 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
 has never produced any other than intermittent fever, or the latter
 any other than continued 1 And is it also equally truqgliat 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 uniformly 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 miarm 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.!  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. in.
t 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, 1 think, perceive  that 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 organised  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.J  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. m. Ait. xiii,
t On Fever, Diss. r. p. 117.
! Elemens de Chiniie, Art. Putrefaction de  Substances Animal, torn, iv, 
46                       HiEMATICA.           [CL. IH.-OR. *•

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 gases  that are let loose  by the putrefactive  decpmpo-
sition ; and hence it is impossible to affirm that the mortality thus pro-
duced is the result of any single or specific miasm operating to this et-
feet.  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 wear
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. III.-OR. I.]     SANGUINEOUS FUNCTION.
47
on the constitution of the individuals it attacks, is as clear as in the
former case : because, in many attacks, we 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  in every • diversity of violence ; commencing with eithei*bf
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
proper place.                                     ,
  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 ail 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 af-
fected ; in others the stomach,  the liver, or a still different organ.
Hiccough and black vomit were common towards the close of the
disease, though  many died without it; and recovery was no exemp-
tion 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 case 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 ;  out 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. 
48                       HiEMATICA.            tCL* nI'-°R- T

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 this 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.!  While 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 its stagnant 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 infested, no sparrow ever appeared."!
   1 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: rtufctifiov h rm  f*ti  totovrui
•pitim f?iAf<d/j; vxtyns tyinro' xxt ov%  tafavro cvrt xXXus,  ovn nipt rciovrtt

  * Essay on the Disease called \ellow Fever.
  t Observations upon the Bulam Fever, which has of late years prevailed in the
West  Indies,  on the coast of America, at Gibraltar, Cadiz, and other parts of
Spain, Sic. in 8vo.  1815.
  \ Reports of the Pestilential Disorder  of Andalusia, which appeared at Cadiz in
the yea.s 1300, 1309, 1310, and 1813, &c.  8vo. 1815.
  h Diemerbr.  De Peste, Cap. vi.  Van Swieten, ex prof. Sorbait, in sect. 1407. 
VL. III.-OR. I.]      SANGUINEOUS FUNCTION.
49
 cvh*.  0< is xvns ftxXXei xi<?6wv irxpuxov rov xTroZutnovrts,  iix to %v^ixi-
 rSirtxt*  Whence Lucretius, who does but little more than translate
 Thucydides :

        Nee tamen omnino temere illis solibus ulla
        Comparebat avis, neque noxia secla ferarum
        Exibant sylvis; languebant pleraque morbo,
        Et moriebantur ;  cum primis fida canum vis
        Strata viis animain ponebant in omnibus aegre :
        Extorquebant enim vitam vis morbida membris.i
        Nor longer birds at noon, nor beasts at night
        Their native woods deserted ; with the pest
        Remote they languish'd and full frequent died.
        But chief the dog his generous strength resia;ii'd,
        Tainting the high-ways, while the ruthless bane
        Through every limb his sick'ning spirit drove.

   There can be  no question,  therefore,  that  the fever before ui
 was in some regions coniagious, or produced from human effluvium ,
 as in other regions, and under other  circumstances, it  was produc-
 ed from marsh effluvium.   The facts brought forward by Sir James
 M'GrigorJ upon this subject are decisive indeed of themselves.  It
 is true  that  Sir James Fellowes and Mr.  Pym  contend,  that  it
 was  produced by contagion alone,  but they completely fail in es-
 tablishing  the question of its importation  by a  ship's crew from
 Spanish America;  and as  there is  no doubt in  the mind of those
 who have not buckled on the armour of controversy,  that this fever
 was the  common fever of the Mediterranean coasts, so well describ-
 ed  by Dr. Cleghorn,   and  which, under different names and with
 different degrees of violence, commits its ravages  mostly about the
 autumnal equinox, from the swampy shores of the Nile to the oozy
 banks of the Tiber, and which is often found as  destructive in the
 Campania  as  in  the East or West  Indies, there  can be no longer
 any  doubt of  the operation of  one  and the same  miasm or febrile
principle in all these cases; sometimes issuing from  the effluvia of
the living body, and sometimes from that of dead organized matter :
 and, consequently, that the whole of that part of Dr. Cullen's sys-
tem is erroneous, which  supposes a  different specific  principle  of
fever to be generated in  each ;  the  one  distinguished  by being-
 limited  to the production of uncontagious  intermittent fever,  and
 the other to that of contagious continued fever.   And  it is of the
 more importance  that the error of this doctrine should be pointed
 out, since it has proved the  very ground-work of that altercation
which has prevailed upon the subject before us.   For  the writers
 on both  sides having  equally  drunk  from the  Cullenian fountain ;
 and, being equally impressed with the  truth of this doctrine, have
only warred with each other in support of Dr. Cullen's  distinction;
and hence those  who have  so clearly witnessed  the  origin of the
 —•—-------------------------------------------------------
           * Hist. xi. 52.
          t De Rer. Nat. Lib. vi. 1217.
          X Medical Sketches, passim.
  VOL. II.              7 
50
IliEMATICA.
[CL. III-OR. V
fever from  marsh effluvium,  that they have been compelled to ac-
knowledge  this as its source, have felt themselves compelled at
the same time to deny that it is  contagious; while those who have
as clearly witnessed its contagious power, have  as  forcibly e
themselves  compelled  to  deny  that it  has  sprung from marsliy
miasm.
  In typhus, or the fever that originates in crowded jails and other
thronged and  noisome  abodes, there is no longer a question con-
cerning its  human  origin and contagious property.   But typhus
does not differ  more widely in its symptoms from some of the mod^"
fications of the fever we have just contemplated,  than such modifi-
cations do  from  others of  the same fever, varied by  the varying
power of its co-operating agents.   And hence, we  have reason to
conclude that  typhus also is  generated from the same  common fe-
brile miasm, modified in its action by influential contingencies.
  In effect the yellow fever itself, under peculiar circumstances,
assumes something of a  typhous character even in  its  first origin,
and where the source has unquestionably been marsh miasm.   This
was  especially the case with the asthenic remittent at Breslaw in
1757, and is still oftener found in  the  remittent that  takes place
along the Gambia, after rain  in the spring  or early part of the sum-
mer, when there is less organized matter remaining on the surface
of the earth to be decomposed,  and what  there is,  has been acted
upon  by a lower  temperature  and  a shorter  duration  of heat than
in the autumn.  " In the month of June," says Dr. Lind, " almost
two  thirds of the white people were  taken ill.  Their sickness
could not  well be characterized by any  denomination commonly
applied to fevers : it however approached nearest to what is called
a nervous fever, as the pulse  was always  low,  and the brain and
nerves seemed principally  affected.  It had also a tendency to fre-
quent remissions."  The patients were often attacked with a diliri-
um, and ran into the open air, where they received benefit from an
affusion of heavy rains upon their naked bodies.  " The delirium
however, it seems, soon returned ;  they afterwards became coma-
tose, their pulse  sunk, and a train of nervous symptoms followed ;
their skin  often became yellow."   And even where the disease has
commenced with  symptoms of great  excitement, and  an  intermit-
tent type, it is so much disposed, under peculiar incidents, as great
fatigue, disappointment,  and short provisions,  to run into a typhus
fever, as at  Walcheren and  during the retreat of the British army
from Corunna, that many nosologists have  thought themselves called
upon to make  this form a distinct variety  or even species of fever,
which they have  usually distinguished by  the name of typhus icte-
rodes, or yellow  typhus.
  In like manner, where the yellow fever has commenced original-
ly from contagion, or in other words from a decomposition of* hu-
man instead of marsh  miasm, it  has been under  the very same
auxiliaries of  filth,  poverty, crowded numbers, and a stagnant at-
mosphere, that give rise to  typhus.  Thus the fever  of Malaga of 
CL. III.-OR. I.]        SANGUINEOUS FUNCTION.               5 \

 1803, uniformly admitted to be of the same kind as that of Cadiz in
 1800, spread  first,  according to professor  Arejula's description,
 through the narrow, crowded, and offensive lanes of the district de
 Perchel:  and that of Cadiz itself, according to Sir James Fellowes,
 made its earliest appearance in  the Barrio de Santa Maria,  a part
 of  the town in which the  streets are narrower, less ventilated and
 cleanly than any other part, and where the poorer inhabitants, dirty
 in their persons and crowded in filthy rooms, generally live togeth-
 er.  It is true that it was conjectured by many persons, and among
 others by both these writers themselves, that the contagion did not
 originate in either of these situations, but was introduced into them
 by  foreign shipping; but such a conjecture has, in the  first  place,
 no  evidence  for its support, and, in the second,  the mere evidence
 of the captain of the ship referred  to was directly contradicted by
 the chief physician of the hospital at the Havannah, who was on
 board the  whole time and was privy to  the  cases  referred to.  In
 effect, a  cause thus  secondary seems to  have been superfluous, for
 the local causes enumerated  by Sir James Fellowes  and professor
 Arejula appear to  have been perfectly adequate.  They are, as
 near as may be, the  same as those which  operate so fatally  in the
 miserable and crowded cabins of Ireland; and  if the fever had  shown
 itself at a cooler season of the year, and  the subjects of  it had been
 still more broken down in constitution by mental dejection  and low
 diet, it would probably from the  first have assumed a  continued and
 typhous character, instead  of a remittent and  more energetic.
  The febrile miasm then, generated by a decomposition of human
 effluvium  and of dead organized matter, appears to  be  essentially
 the same,  modified alone  in  one or two or  its qualities by the co-
 operation of the heat, moisture,  stagnant atmosphere, and  perhaps
 some other unknown agents, that are necessary to give it birth or
 activity.
  The chief difference produced in this miasm under these distinct
 modes of origin is, that  when generated  by the  decomposition of
 effluvium  issuing from living human bodies, it  is less volatile, and
 has at the same time a power more directly exhausting, or debili-
 tating the sensorial energy, than when generated by the decompo-
 sition of dead organized matter.   Whence fevers originating in jails
 or other confined and crowded scenes  contaminate the atmosphere
 to a less distance than those from marshes or other swamps, but act
 with a greater degree of depression on  the  nervous  system  when
 once received into it.
  In whatever mode derived,  the remark of  my excellent and dis-
 tinguished  friend Dr. Hosack will  still  hold, not indeed  that it is
 altogether incapable of taking effect in a pure atmosphere, but that
 " an impure atmosphere is indispensably necessary to extend the spe-
 cific poison."*  And I'should also  fully concur  with him in censuring
  * Observations on the Laws governing the communication of contagious Dis
eases, 4to. New York, 1815. 
52                     H^MATICA.               [«- in.-o*- h
the application of the term  epidemic to any of the  febrile diseases
hereby produced, provided  this  epithet  were  usually confined,
which I am not aware of, to disorders supposed to result from some
primary 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
«uch impure air is less,  while those who reside  in  the pure air oi
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 aay 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 Haygarth. 
>CL. III.-OR. I.]
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.   Arid 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, producer a miasm similar to that  generated by a
decomposition of dead organized matter, and hence, capable of be-
coming 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 typh-
ous contamination around them,  are  affected far less  readily than
strangers; and, in numerous instances, are not affected at all. 
54
HAEMATIC A.
[CL, III.-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 expres-
 sed 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,  1 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
attention  as a question of history,  and which may yet be of great
importance to many parts of the world.
   If we examine the  phenomena of the animal economy, as they
occur in ^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. III.-OR. I.]
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 h's  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 vmy 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  cften that they extend further.
  In other parts of bis works, he regards also the 4th  and  6th fttid
even the 21st «-.s 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 necessary 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 exacerbation, and no
one day is more critical than any other.   Alter 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                       ILEMATICA.            [«- 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 Cullen  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,  admitted 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 practice. J   Why the first week of  a  fe-
 ver should incline to a quotidian type rather  than to  a  tertain,  or
the second to a tertian 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, tertian,  or quartan,  have their paroxysms recur
regularly in the day time ; the quotidian in the morning, the tertian
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 take  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 phenomena is sought in
the influences of the heavenly bodies, and especially in those of the
sun and the moon.  In ancienttimes these luminaries were supposed
to produce an effect on all diseases, and especially on mania, epilepsy,
catameuia,*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 give it  an air of serious importance.  Dr. Bal-
 four, of British India, however, has still more lately brought it for-

        * De Hoinine.
         t Rat. Med.  Part iv. p. 283.
         X Du Prognostic dans lee Maladies Aigues, 8vo. Morrtpel. 1778. 
 CL. III.-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 state  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 physician 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-
 demics and pestilences.
voi.  n. 
■'>*»                       H/EMATICA.
                       GENUS  I.


                       EPHEMERA.

                       JBtarg iTefcer.

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 degree  in all  the  subdivisions that
appertain to it.
  I have said that the ephemera rarely exceeds a duration of twen-
ty-four hours.   Sorne 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 MIT1S.             MILD DIARY FEVER.
   2- --------- ACUTA.            ACUTE  DIARY FEVER.
   3<---------SUDATORIA.         SWEATING-FEVER.
[CL. IIL-OR. I.
" <>n Simple Fever, Diss. i. p. 33. 
                    SANGUINEOUS  FUNCTION.               59


                         SPECIES I.

                 EPHEMERA  MITISl

                   $Htl& Bt'arg iPctoer.

WITHOUT  PRECEDING  RIGOR J LASSITUDE AND DEBILITY INCONSIDERABLE ,
  PAINS OBTUSE, CHIEFLY ABOUT  THE HEAD ; HEAT AND NUMBER OF THE
  TULSE INCREASED SLIGHTLY :  PERSPIRATION BREATHING AND PLEASANT.

The common exciting causes are, excess of corporeal and especially
of muscular  exertion ;  long  protracted  study;  violent passion;
suppressed 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  latter 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  ojutlet' 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 interrupted  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
GE. I.-SP. I.] 
 60                       HJEMATICA.             [CL. ML-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  general welfare  of the animal frame, will be  usually found
 competent to its object.  So that if any thing remedially is attempt-
 edr it should be confined perhaps to a slight increase of the peris-
 taltic 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 power, while its own diaphoretic quality continues
 at least  undiminished and is  often improved.  This is now well
 known, though not a discovery of recent date; for  Gianella, Valer,
 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 cold 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-
 rally found persons  who have  adopted this  practice  become debili-
 tated and dropsical, and  sink into an untimely grave, or creep  on
 miserably through the fag  end of a lingering life,  that affords  no
 retrospective comfort, with a hospital of diseases about them.   But
 whether this proceed from the  practice adverted  to, or from the
 habitual  exhaustion  which necessarily  accompanies a  course  of
gambling, may admit  of a doubt.   Vet, the habit itself appears
mischievous, however pleasant  at the  time,  as having a strong
tendency by frequent  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 Ipecacoanhae virtute in curandis febribus, &c. Patav
1754.—Vater, Diss, de Ipecacoanhie virtute febxifuga, &c. Witeb. 1732. 
GE. I.—SP. II.]      SANGUINEOUS FUNCTION.
61
                        SPECIES II.

                EPHEMERA  ACUTA.

                    &cute 3Marg iFetoev.

SEVERE RIGOR ; GREAT HEAT ;  PULSE AT FIRST SMALL AND CONTRACTED,
  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, is 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 tfee 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.
  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
ILEMATICA.
[CL. III.-OR. L
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 in  a diurnal revolution; and no tendency to a return of the
paroxysm be produced.
  If the species before  us,^iowever 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 Forestus
gives  a case  in which the  paroxysm led to a 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.

                     Sfoeattug=iFe&n\

TENSE PAINS IN THE NECK AND EXTREMITIES ; PALPITATION ; DYSPNQKA ; PULSE
  RAPID AND IRREGULAR ;  HEAT INTENSE ; INTOLERABLE THIRST ;  DROWSI-
  NESS 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 Anglieus 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.
            t Cent. ii. Obs. 100.
            X Institut. Med. Pract. 8vo. 4 Tom. Ven. 1782-5. 
GE. I.-SP. III.]       SANGUINEOUS FUNCTION.
63
dous as that of 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 h£at 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 regu-
lar 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 gmin, pcUlicularly wheat,
which is less hardy than other grains  and soouer infested with albi- 
 64                      HJEMATICA.             [CL. III.—OR* '•

 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 own 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.  Freind 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,  crossed 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 vexy 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 field.]:
   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 sueti
 dicta, sudorifera ?" has maintained Dr. Coste's opinion.
* Hist, of Physic. Vol. n. p. 533.
t Art of Preserving Health, B. m.
X Na-vier, Maladies Populaires, &c. 
€E. II.]
SANGUINEOUS FUNCTION.
65
                      GENUS  II.


                          ANETUS.

                Xntmnfttent jFcfcer.  ®q\w.

PAROXYSM INTERMITTING, AND RETURNING DURING THE COURSE OF THE DIS-
      EASE :  THE INTERMISSIONS GENERALLY PERFECT AND REGULAR.

Under the preceding genus, the remote cause, whatever it consists
in, lays a foundation for not more than one paroxysm.  In the genus
before us, the cause introduces a  tendency to  a recurrence of the
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-miasm—miasmate paludum ortcz—
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 form 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, sometimes 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
principii hie admittimus, licet ncutiquam  excitussent, si miasma palu-
dum non antea  applicatum fuisset."  But this  is the very point of
controversy ;  for in many instances they produce the disease where
marsh-miasm cannot be suspected.   1 have seen an  isolated case of 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. 11.               ^      9 
m
H.EMATICA.
[cl. m.r-0R. r.
  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  type.   Dr.  For-
.  dyce affims, 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 affection, 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.J
   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 Min-
  orca,  is sometimes attacked with remittent of 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 n. ch. iv. p. 411.
t Act. Soc. Med. Hafn. Tom. i. N. 10.
X De Putridine, Urbin, 1608.
& Med. Trans. Vol. in. Art. xiii.
!l Cleghorn,  Diseases of Minorca
* 
f«. II.]            SANGUINEOUS  FUNCTION.                67
fee 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 mere-
ly 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 all 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.  ------QUART ANUS.             QUARTAN AGUE.
   4. ------ERRATICUS.             IRREGULAR AGUE.
   5. ------COMPL1CATUS.           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                       HvEMATICA.            [CL. 1H.-OR. 1-

   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 1 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 particu
larly noticed under the species itself.
                        SPECIES  I.

              ANETUS  QUOTIDIANUS.

                     <&UQtftiau SQur.

INTERMISSION ABOUT EVERY TWENTY-FOUR HOURS :  PAROXYSM  COMMENC-
   ING IN THE  MORNING :  USUAL  DURATION UNDER  EIGHTEEN HOURS.

The genuine  quotidian  is of  less  frequent  occurrence,  than the
other species ;  but it has a considerable resemblance to that variety
of the complicated intermittent, which has generally been denomi-
nated a double tertian, and with which it is often confounde'd.  It is
distinguishable, however, to an attentive eye by the regularity of 
GE. II.-SP. I.]*      SANGUINEOUS FUNCTION.                 69

its paroxysms, which is true to itself on every return; while in the
double tertian the alternate paroxysms only are true to each other
as we shall have occasion to observe  more particularly in the pro-
per place.  The quotidian, like  the tertian and quartan,  has some-
times been epidemic.
   The quotidian intermittent is occasionally limited in its attack to
a particular part, and is  occasionally connected  with other affec-
tions.  It deviates also now and then from its common rule, in hav-
ing an imperfect intermission, and in precipitating or procrastinat-
ing every  subsequent paroxysm: and hence, affords us the follow-
ing varieties:—

       a Partialis.                  Partial quotidian.
       6 Comitatus.                Catenating quotidian.
       y Protractus.                Protracted quotidian.
       3 Anticipans.                Anticipating  quotidian.
       e  Cunctans.                  Retarding quotidian.

   In the partial quotidian,  the febrile attack is confined  to  a par-
ticular part or organ, and usually accompanied with distressing pain.
   Under this modification, sometimes  one side of the body has suf-
fered,  while the other has escaped: sometimes one or both eyes;
but  more generally the whole or half the head, not unfrequently
resembling cases  of cephalaea, and particularly that  species of it
which is called hernicrania.
   In the catenating quotidian, the disease associates with or gives
rise to various foreign symptoms or other diseases.   And hence, is
often found in union with rheumatic affections, particularly lumba-
go and  sciatica.  Sauvages quotes a  case  in which it  associated
with daily attacks of a frightful  epilepsy*  And  Dr. A.  Munro, in
the Edinburgh Medical Essays, narrates a similar instance, though
less severe, and alludes to several others that had occurred to him.f
Torti has made  a collection of numerous examples of this variety,
and has united them into one family,  under the name of  febres in-
termittentes comitatae.   Galen has  described  one or two of  them
under the name  of epiala.
   In the protracted quotidian, the intermission is inordinately short
or imperfect.  In the former case the paroxysm is  lengthened be-
yond the usual  period of eighteen hours; and  in the latter case
does so completely subside as to leave  the intermission totally clear
of febrile symptoms.  On which last account the  Latins  described
this variety under the name of quotidiana continua; and the Greeks
under that of amphemerina.
   In the  anticipating quotidian,  which is the name  given to our
fourth variety by Dr. Fordyce,  the paroxysm precedes its antece-
dent period usually by about two hours, and continues the same fore-
march  at  every recurrence; so  that the  accession may hereby be
thrown into any  hour of the day or night.
* Class ir.  Febr. Intermit.  Quot. Spec. iv.
t Vol. n.  Art. xix. 
70                      H2EMATICA.             [CL« 1"'-°K-  L

  The retarding quotidian, which,  like the last, has  been partl£«-
larly noticed  and named  by Dr.  Fordyce, forms a direct counie*"
part to the anticipating; the paroxysm delaying its  antecedent
period usually by about  two hours, and continuing the same aeiay
at every recurrence ; so that here also the accession may be  tnrowu
into any hour of the day  or night.                         ,.    .
  There  are  few diseases, moreover, in which the quotidian  is
not occasionally to be found as a symptom ; but it occurs especially
in  hysteria,  catarrh, gout,  peripneumony, ischury, quinsy,  ana
several species of odontia.
                        SPECIES II.

                ANETUS TERTIANUS.

                      ©ertfau &gue.

INTERMISSION ABOUT  FORTY-EIGHT  HOURS :  PAROXYSM COMMENCING  AT
           NOON: USUAL DURATION UNDER TWELVE HOURS.

The tertian ague, the tritaeus of the Greeks, occurs most frequently
in the spring and summer months ; though there is a spurious kind
that shows  itself in the autumn.  The chill,  during the  cold fit, is
intense, with convulsive shivering, rigidity, and  gnashing of the
teeth.  It is, however, of shorter duration than that of the quar-
tan, and sometimes passes off in less  than half an hour;  and is suc-
ceeded first by nausea or vomiting, and afterwards by a pungent
penetrating heat, frequent respiration, urgent desire for cold drink,
wakefulness,  and  head-ache,  sometimes  delirium.  At  length a
moisture on the  skin, gradually advancing  to a copious  sweat,
breaks forth,  the urine commonly deposits a lateritious sediment,
and there is often some looseness of the bowels.   The  entire  pa-
roxysm sometimes ceases in six hours,  but more generally extends
to eight or ten ;  if it exceed twelve, as it does occasionally in the
autumn, the disease forms the  spurious tertian  I have just alluded
to.   As the quotidian is mostly  common to infants and persons of
delicate habits, the tertian chiefly affects those of riper years or of
firmer fibres, and especially persons of a  bilious temperament.   It
was the opinion of Hippocrates that the tertian ague, if left to  na-
ture, would run itself out in seven paroxysms; and Vogel adds, that,
when this  is  the case, there is usually  the appearance of a dry
scabby eruption about the lips on  the fourth  or fifth  paroxysm.
But the period pointed out by the former does not hold in our own
day; and the disease has often  continued obstinate in spite of cuta-
neous eruptions, not only about the lips but over the body.   Syden-
ham asserts, that in the autumn, in which, however, a genuine ter-^ 
GE. 1I.-SP. II.]         SANGUINEOUS FUNCTION.              71

tian is rarely to be met with, its ordinary  natural course is double
the term allotted by Hippocrates,  or rather that the term of its pa-
roxysms  amounts to the space of  fourteen days.   I he  tertian ex-
hibits occasionally the two following varieties :

       x Comitatus.                    Catenating tertian.
       C Protractus.                    Protracted tertian.

   To both  which the  explanation  already given  under the same
terms in the preceding species will  equally apply.   As an associate
disease, it is chiefly to be found united with syncopal and soporose
affections, indicating some oppression of the brain; or with cholera,
or dysentery, mostly indicating irritation or congestion in the liver.
   It is also  to be  traced  occasionally as  a species in  syphilis, sea-
scurvy, worms, and scabid eruptions.
                        SPECIES III.

                ANETUS  QUARTANUS.

                      <&uman gfgue.

INTERMISSION ABOUT SEVENTY-TWO HOURS. :  PAROXYSM  COMMENCING IS
       THE AFTERNOON : USUAL DURATION  UNDER NINE HOURS.

This, which is  also the quartana of Celsus, is the tetartaeus of the
Greek writers.   It is rarely found in the vernal season, but is com-
mon in the autumnal; in which quarter, also, it is far the most obsti-
nate of all the species, and especially if, as Celsus observes, it show
itself only a short time before the commencement of winter.  Its
chief subjects  and sufferers are those  of advanced years, and of a
melancholic habit; for children  and young persons, who principally
feel the effects  of the two ormer species, are but little  obnoxious
to it.  It commences usually about or a little before five o'clock in
the  afternoon.   The cold  fit is less vehement than in the tertian,
but of longer duration, and will sometimes continue for two hours,
but usually  without sickness or diarrhoea.  It yields to a heat that
is rather troublesome from  its dryness than from its intensity, and
which is rarely succeeded by a sensible perspiration.   There is a
heaviness or dullness in the head rather than acute pain; and often
during the intermediate days, a sense of soreness over the body, as
though it had been generally bruised, which strikes through to the
bones.  It is here also we principally meet with parabysmic tu-
mours, and especially of the spleen and  liver: in the former of which
organs they are vulgarly called ague-cakes. 
72                    1LEMATICA.              [CL.IU.-OR. I.

  The quartan oflers the following varieties:—
       *  Comitatus.                 Catenating quartan.
       C  Protractus.                 Protracted quartan.
       y  Anticipans.                 Anticipating quartan.
       §  Cunctans.                  Retarding quartan.

  Of all which an explanation will be found by turning to the same
varieties  under the first species.                             .   .
  From the tendency which this species has to affect the  abdominal
viscera, it is often met with as a symptom in diseases of the spleen,
liver,  and various adjoining organs.
                       SPECIES IV.

               ANETUS ERRATICUS.

                     Krvroular &gue.

INTERMISSION  AND PAROXYSM POSSESSING LITTLE REGULARITY :  THE FOR-
               MER MORE THAN SEVENTY-TWO HOURS.

We have already perceived that there is occasionally some degree
of irregularity in all the preceding species, least of all, however, in
the quartan.   And hence all the above might, in such instances, be
named erratic.  But the peculiar character of  the present species
is, that the duration of the intermission exceeds that of all of them;
on which account it can never be confounded with any of the rest.
  The chief varieties are the following; which, however might be
considerably enlarged, but it is unnecessary.  They are principally
taken from Sauvages and Vogel:  and for other authorities the rea-
der may turn to the volume of Nosology.

       x  Quintanus.                  Five-day ague.
       |3  Sextanus.                   Six-day ague.
       y  Septanus.                   Seven-day  ague.
       3  Octanus.                    Eight-day  ague.
       e  Nonanus.                   Nine-day ague.
       £  Decimanus.                 Ten-day ague.
       ti  Vagus.                     Vague and irreducible.

  Several of the above have occasionally persevered with great ob-
stinacy ; in some instances for upwards  of two years without ceasing.
The iast variety is equally irregular as to the violence of its par-
oxism, the  duration of its stages, and the period  of its return.
Sereral of Sauvages's  species of hernicrania may be properly re-
ferred to this place, and especially those, which, by some writers,
have been denominated ij^ermittentes larvate,  or disguised inter-
mittent*. 
■E. II.-SP. V.]
SANGUINEOUS FUNCTION.
                        SPECIES V.

              ANETUS COMPLICATUS.

                     (ftomjrttcatcti &fltte.

           paroxysms intricate, multiplicate,  or both.

There are numerous examples of ague which, to an inattentive eye
are as irreducible to any regular  order as  those which belong to
the last variety of the preceding species; but which, when minute-
ly examined, are found, however intricate, to be composed of types,
not that uniformly resemble each other, but that recur in alternate
sets, every set  being true to itself, while it differs from that with
which it alternates in the duration of its intervals, or of its parox-
ysms, or of the time of its accession.   And hence, although  in some
shape or other, most of them return perhaps  every day,  and are
often mistaken for irregular quotidians,  they are, in fact, double  or
triple tertians, or  quartans, discovering their real nature by these
alternating distinctions.
   The following are the chief varieties :—
x Tertianus duplex.
  Double tertian.
i Tertianus triplex.
  Triple tertian.
y Tertianus impar.
  Double unequal tertian.

3 Tertianus duplicatus.
  Duplicate tertian.
Quartanus duplex.
Double quartan.
£ Quartanus triplex.
  Triple quartan.

  vol. tt.
The paroxysms of the one ter-
  tian occurring in the intermis-
  sions of the  other:  and the
  two sets evincing a difference
  of duration or of violence.
A  double  tertian, taking  place
  as above ;  but one of the sets
   having  regularly two parox-
  ysms on the day of its return,
   and the other, one alone.
The one  set evincing a  more
   perfect, the  other'a less per-
  fect intermission.
Being a single  tertian with two
  paroxysms on the  regular day
  of attack, the intervals  being
   of ordinary duration.
The paroxysms of the one set
   occurring in the intermissions
   of the other; and evincing a
   difference  of duration  or  of
   violence : with an interval on
   the third  day alone.
Consisting of a single quartan
   with  regularly returning pa-
   roxysms ;  while each of the
10 
74                      HjEMATICA.              [cl. III.-OR. I.

                                    intervening days  is  marked
                                    with a  slighter or  separate
                                    attack.
                                  Consisting of a single  quartan;
                                    with two paroxysms on  the
                                    regular day of attack: the  in-
                                    tervals being of ordinary dura-
                                    tion.
                                  Consisting  of a  single  quartan
                                    with three paroxysms on the
                                    regular day of attack : the  in-
                                    tervals being undisturbed and
                                    of ordinary duration.

  Having thus distinctly noticed the several species  and chief varie-
ties of intermittent fever, I  shall proceed to  offer  a few remarks
upon its general history, and medical treatment.
  Whenever the accession of an intermittent is violent,  be its type
what it may, it  is sometimes attended with  very  alarming symp-
toms,  as  syncope, apoplexy, vehement spasms over  the whole sys-
tem, or a coldness  or torpor  which  threatens  death.  Yet,  when
not violent, nor of very long duration, and especially when of the
tertian type, it is  often serviceable to the general health, and car-
ries off many chronic and lurking disorders of other  kinds : Dr. For-
dyce  affirms that he has seen it of considerable use in  curing or
alleviating chronic  rheumatism,  habitual indigestion,  cutaneous
eruptions, protracted inflammations, epilepsies, and hysteria.*  And
his assertion is corroborated by other authorities.!
  The duration  of  intermittents is of great uncertainty.  The ver-
nal agues generally  disappear  with the advance of summer: the
autumnal are more  obstinate,  and  especially the quartan.  Where
they have remained long, and have become habitual, even their  re-
moval must be  attempted with great caution;  for when abruptly
suppressed, they have been known  to lay a foundation for a host of
other maladies, often of a more fatal description, as paralysis, vari-
ous visceral affections, and even sphacelus.
  Ludolf gives an  instance of an eight-day  ague (anetus erraticus
octanus,) continuing for eighteen years;  yet this   was  probably a
double quartan;  while we have abundant examples of a continuance
of the regular quartan for nine,J twelve,§ eighteen,||  twenty,IF twen-
* On Fever, Diss. 11. p. 16.
t Salmuth, Cent. 11. Obs. 14.—Ephein. Nat. Cur. Dec. hi. Ann. m, Obs. 30.
X Eph. Nat. Cur. Dec. n. Ann. vm. Obs. 45.
i Avicenna, Fen. I. Lib. iv. Tr. II. Cap. vi.
II Madai, Von Weekselfiebern. Sect. 144.
11 Eph. Nat. Cur. Dec. hi. Ann. is. and x. Obs. 51.
»j Quartanus duplicatus.
  Duplicate quartan.
t Quartanus triplicatus
  Triplicate quartan. 
GE. II.-SP. V.]        SANGUINEOUS FUNCTION.
75
 ty-four,* and thirty years,t and one instance of it lasting for not less
.than  forty-eight years.|   It is in this species therefore,  that we
 chiefly meet with  those congestions in the spleen which are called
 ague-cakes, as also with  scirrhosities in  the liver, pancreas, and
 other abdominal organs, which by Bonet, Swalwe, Senac, and other
 writers have been regarded as  causes of  the disease,  but  by Van
 Hoven, and all the pathologists of the present day, are more correct-
 ly resolved into effects.
   Schenck gives a case of congenital quartan,  or in  which it ap-
 peared in  an infant immediately  after birth ;§ and  Paullini another,
 in which,  though not strictly congenital, it appeared in very early
 infancy.||   But such examples are rare.  Among other singularities,
 I may observe, that, the accession has sometimes been  so violent as
 to destroy the patient in the course of the first paroxysm, of which
 an instance will be found in  Senac,1T while at other times it has been
 so slight and rapid, that the entire  paroxysm has run  through its
 course in a minute.**
   The character of the intermittent seems in a considerable degree
 to depend upon the age or idiosyncrasy of the individual  and the
 temperament of the atmosphere.   We  find also that variations
 more usually take place in the quotidian  than in  any  other type,
 which we should, perhaps, ascribe to  its occurring more frequently
 in early life, when the frame is more  irritable ; and to  the greater
 debility which the constitution suffers from this type above  that of
 any other, in consequence of the greater length of its paroxysms,
 and the greater brevity of its intervals, by which  means the pros-
 trated strength  of the system  has no  time to rally or recover it-
 self.
   In  this metropolis,  from causes which have not been handed down
 to us, and  which, indeed, do not  appear to  have been traced at the
 time, intermittent fevers  were more than ordinarily  frequent  from
 the year 1781 to 1785 :  and  the  remarks I have just made apply in
 an especial manner to all these.   As a single example, let us select
 those of 1782, as described by Sir George Baker and Dr. Reynolds,
 in an article drawn up by the former  with  an admirable combina-
 tion of learning and liberality, sound critical judgment, and inquisi-
 tive research.
   " The type of the fever of 1781-2," says  Sir George," was either
 tertian or quotidian;  the former  being more  common in the first
  * Marcellus Donetus, Lib. m. Cap. xiv. p. 291.—Pontanus, De. Nebus ConeL
L. vm.
  t Binninger, Obs. Cent. v. N. 64.  Wierius Obs. p. 37.
  X Gabelchover, Cent. vi. Obs. 74.
  i Obs. Lib. vi. N. 36.
  || Cent. i. Obs. 94.
  1F Von Weekselfiebern, B. ii. Cap. vi.
  •* Reil, Memorab. Clin. Vol. H. Fasc. i 
76
H^MATICA.
[CL. III.-OR. L
part of the winter; the latter from the middle  of February to the
end of June.  With respect to the former nothing occurred  to my
observation which is worthy of notice.  On the latter, Dr. Reynolds
has communicated to me the following remarks : and any  addition
would be unnecessary relative to a  subject which he has  so  well
exhausted."*                                               .  .
  This communication is too long to be  copied verbally,  but  it is
fully entitled to the praise which the learned baronet has  bestowed
upon it.  It will be sufficient for our present purpose  to  transcribe
its leading  features.
  Dr. Reynolds, in his communication to Sir George  Baker, tells us,
that the quotidian fevers of the above year were irregular in their
invasion, and uncommon in their appearance ;  and that no cases re-
sembled each other except in very few circumstances.   The first
attack  generally  commenced with a horror;  but the  subsequent
paroxysms,  though often beginning with a sense of cold, were
chiefly without horror.  The intermission  was short and seldom
perfect.  The symptoms were very severe,  and in many  cases dan-
gerous, and leaned strikingly to a typhus form.  Great and  sudden
oppression of the head, anxiety, depression of spirits, a dry, parch-
ed, tongue, yet less covered with hardened  mucus than  might be
expected; a pulse-low, quick, and  intermitting;  bowels  variable;
urine dark-red, and clear without any sediment, constituted the or-
dinary  signs.   Many had a low muttering  delirium ;  two  or three,
a laborious respiration ; a few, spasms  and twitchings of the ten-
dons ;  aphthae  appeared occasionally; and  one  patient  exhibited
symptoms of violently acute rheumatism.  The bark  was universal-
ly successful;  and, " I was as much pleased," says  Dr.  Reynolds,
" with  its present efficacy, as I was in the year 1781 mortified by
its extraoidinary want  of power.   Half the quantity  of it  which I
used on that occasion was sufficient on this."
  In other words, idiosyncracy and atmospheric temperament were
both peculiarly visible, and  gave a peculiar character, in  the  one
instance to  particular cases, and in the other to the general disease.
In plethoric habits the head was  greatly oppressed, with a tenden-
cy to delirum.  In those of a nervous or  irritable disposition  the
intermittent was connected with spasms  and twitchings of the ten-
dons.   And those disposed to rheumatism had acute arthritic pains.
The state of the atmosphere, and general character  of the season
Dr. Reynolds has forgotten to notice :  but we see  evidently  and
indeed he himself allows, that they gave  a  typhous  impression to
the epidemic; which, from the same or from other causes is also
peculiarly distinguished by the easy victory it yielded to  the use of
the bark: as that of the preceding year was distinguished by its ob-
stinate resistance to this medicine.
  If we ascend a year higher, or to 1780-1, we shall meet with an
equal diversity of symptoms.   " These fevers (intermittents,") says

            Medical Transactions, Vol. m. Art. xiij. 
GE. II.-SP. V.]     SANGUINEOUS  FUNCTION.
77
Sir George Baker, " were  in general  no other than the common
ague ;  but in the more inland counties of England, they were often
attended with peculiarities extraordinary and alarming.  For the
cold fit was accompanied by spasm and stiffness of the whole body;
the jaws being fixed, the eyes staring, and the pulse very small and
weak.—In many cases delirium was  added to spasm, under  both
which  symptoms the patient laboured quite to the end of the parox-
ysm.   And,  though  the  senses returned when the  fever  subsided,
yet a convulsive twitching of the extremities continued even in the
intermissions, to such a degree, that it was not possible to distinguish
the motion of the artery at the wrist.
   " This fever had every kind of variety; and whether at its first
accession it were a quotidian,  a tertian, or a  quartan, it  was very
apt to  change from one type  to  another.  Sometimes it returned
two days successively, and missed the  third, and  sometimes it be-
came  continual.  I  am not informed  that any died  of  this fever
whilst  it intermitted.   It is, however,  certain that many country
people, whose illness had,  at its beginning, put on the ^appearance
of intermission, becoming delirious, sunk under it in four or five days.
It is a  remarkable fact and very well attested, that in many places,
WHILST THE   INHABITANTS  OF  THE HIGH GROUNDS WERE HARASSED BY
THIS FEVER,  IN ITS WORST FORM,  THOSE OF THE SUBJACENT VALLIES
were not affected by it.   The people of Boston and of the neigh-
bouring villages,  in the midst of the Fens, were in general healthy,
at a time when this fever was epidemic in the more elevated situa-
tions of Lincolnshire.  It is likewise singular, and worthy of notice,
that in many  families the female servants were  nearly  exempted
from a disease which very few male  servants, especially the  la-
bourers in the open air, escaped.  But the distinguishing character
of this fever  was its obstinate resistance to the Peruvian bark; nor,
indeed, was the prevalence of the disease more observable than the
inefficacy of the remedy.   Though the quantities of the bark usually
given  were  exceeded, the fit was apt to return, ^rarely  altered,
either  with respect to the time  of  invasion, or the  intenseness of
the symptoms ; and just as  If no means had been used to prevent it.
A drachm of  the bark in powder was frequently administered every
second hour without averting the fit."*
   In casting our eyes over the  great  diversity of medicines that
have been employed for the cure of intermittents, we shall find that,
innumerable  as they are, they  may be arranged under two  general
heads,  tonics  and antispasmodics; as though, long before  the  time
of Dr. Cullen, his two principals of the disease, debility and spasm,
had been uniformly admitted and acted upon.
   The antispasmodics, consisting chiefly  of stimulants,  sedatives,
and relaxants, have been confined to the term of the paroxysm, with
a view to weaken and shorten it; and the tonics, consisting princi-
pally of bitters and astringents, have been employed throughout the
'■  Med, Tran?. I.uc. citat, 
78
HvEMATICA.
[CL. III.-OR. I.
intervals with a view of fortifying the system against a recurrence
of the attack.
  In discussing the medical treatment of intermittent fevers,  it will
be sufficient to limit ourselves to these two indications.
  It was a favourite  practice with Bergius to anticipate the cold fit,
constituting the accession of the paroxysm, by pungent stimulants,
in the hope that if he could successfully combat this first stage, he
should gain a complete victory, not  only  over the individual pa-
roxysm, but over  all future  incursions.   His favourite  medicines
for  this purpose were garlic, mustard-seeds, and capsicum, which in
his  day was described under the name of piper Indicum.  And he
boasts of having, in numerous instances, completely succeeded with
each of these ; though he admits that the mustard-seeds answered
best in vernal intermittents, and did not in general  prove  sufficient
for the autumnal quartans.  His chief  reliance was placed  on the
capiscum, six grains of which he was in the habit  of  giving,  com-
bined with two scruples of bay-berries in powder,  "incipiente pri-
mo  rigore*?' and of repeating it every day,  at the same hour for
three or four times in succession.   And he  assures us that he has
very frequently seen obstinate intermittents removed  by this  pow-
der, and without any relapse.
  The practice, however, has not been equally successful in other
hands; not even when capsicum has been given in a  much  larger
quantity,  or  exchanged  for  ammonia, treacle-mustard (clypeola
Jonthlaspi,) or black  or white-pepper, the latter of which is only the
former denuded of its outward tunic, mixed up with brandy or hol-
lands.  They have all, indeed, sometimes answered, but  the  result
is uncertain; and, as was  long ago  observed by  the  Baron  Van
Swieten, if  the medicine did not succeed upon a full dose, and es-
pecially when combined with ardent spirit, it will  often  extend its
influence to the hot fit, and greatly exacerbate it; and not  unfre-
quently convert an intermittent into a continued fever.  Upon the
whole,, therefore, this plan is not to be recommended, however va-
ried.   The least pernicious material is the ammonia, but then it is
also the least effective.
  A large draught of cold water has been not unfrequently had re-
course to for the same purpose, and also, in a  few instances  with
success.  The object is, by taking it about half an hour before the
cold fit is expected, to excite a strong  reaction and powerful  glow
over the entire system against the time when  the  cold  fit returns
and thus to pre-occupy the ground; and, by disturbing the regularity
of the type, to subdue the intermittent altogether.  But this plan
has, perhaps, more frequently failed than the preceding : and when
the shivering or horripilation produced by the  cold water has not
been  followed with a stimulant effect, as  in delicate  habits more
especially, it has often continued so long as to run  into the term of
the febrile cold fit, and  very considerably  to increase  its power.
Ballonius relates a case in which it proved fatal*
* Opp. Tom. k p. 193. 
GE. II.-SP. V.]         SANGUINEOUS FUNCTION.              79

  The next division of antispasmodics which have been directed
against the paroxysm,  and especially against the rigor  with which
it makes its onset, is sedatives, and  of these  the chief have been
opiates, which, when given in the form of laudanum  in  a dose of
from thirty to forty drops  at the commencement of the chill, has,
in many cases of intermittents, been  highly beneficial; diminishing
the duration of the stage,  and moderating its symptoms.  Dr. Trot-
ter says, that he practiced this plan with  general advantage in an
epidemic intermittent that attacked the  Vengeance,  one of the
channel fleet under Lord Howe: and  adds, that, " if the first dose
of opium did not produce a sensible relief and exhilaration of spirits
in half an hour, he repeated it, and never found it necessary to go
beyond a second dose."
   We have already seen,  however,  that  there is some  cause or
other, probably the peculiar state of the atmosphere at the time,
that baffles on one occasion the remedy that has best  succeeded on
another.  And  hence opium has often failed in other intermittents
in every form, but especially  when given in  the cold fit.   And ow-
ing to this diversity of effect,  Dr.  Lind thought it most useful in the
hot fit; and asserts that, if administered to  the  extent of twenty or
five and twenty drops  of laudanum half an  hour after the beginning
of the hot fit, it produced the advantage of shortening and  mode-
rating the heat, calmed the anxiety and  head-ache which  are usual
concomitants, expedited the sweating stage, made the paroxysms
more regular, and sometimes stopped the fever altogether.
   Other physicians have  commenced with relaxants; and where
 these are selected, the antimonial  preparations are  to be preferred
to ipecacuan.  They tend more directly towards the surface, and,
where it is useful  to excite  vomiting, which is often the case, they
act sooner, and maintain the action longer, and hence  make a dou-
ble  effort  to accelerate the sweating stage.   These  preparations
differ chiefly from each other by having the reguline part of the
 antimony  they contain in a more  or less  fusible state ; and their
 operation will  often vary according to the  quantity or quality of the
 acid they meet with in the stomach;  and hence the different effect
 of the same preparation in different  persons, and even in the same
 person at  different times.  The  rubinus  antimonii, or  antimonial
 febrifuge of Craanen,  was at one time regarded as a specific in in-
 termittents on the continent, and was  in particular  favour with
 Stahl, Dieterech, Vogel,  and  many other physicia is of reputation ;
 but it does not appear to  be of superior  efficacy, in any respect, to
 the antimonial powder of the  London Coliege.
   The most efficacious practice  which I  have witnessed, consists
 in uniting relaxants with opiates; and, where this joint effort is  pur-
 sued, ipecacuan  may answer  as well as any of the preparations of
 antimony.  We cannot have,  for this purpose, a more  useful medi-
 cine than  Dover's powder; and it should be commenced with much
 earlier  than is consistent with the usual  practice, so as not to re-
 gulate the hot and sweating stages,  but to anticipate  the cold fit. 
80                       HAEMATIC A.           [CL* IIL  (
And we may still farther add to the ingredients of the medicine  a
full dose of volatile alkali with  great  advantage ; for it is in  ink
form, if in any, that we can employ stimulants  with  a certainty oi
doing little  mischief,  and very nearly a certainty of considerable
benefit.   In the  case of a quartan in St. Thomas's  Hospital  wmcn
had lasted two years, Dr. Fordyce determined upon this plan ;  and
prescribed a full dose of Dover's  powder  with a sweating draught
of carbonate of ammonia two hours before the paroxysm was ex-
pected.   It succeeded perfectly.   A  profuse  perspiration  antici-
pated the period of the cold fit, and hereby entirely  prevented it;
bark was next given freely, and this obstinate  ague was cured in a
few days.*                                               .
  How far the use of Dippell's  or any other animal  oil might be
serviceable as an antispasmodic in intermittents, I cannot say.   Dr.
Hoffman was highly impressed in their favour ;  and asserts, that a
single dose of from twenty to  thirty drops, given six  hours  before
the accession  of an intermitting  fever,  will  frequently prove a
complete cure to th£ complaint.  'J hey appear  certainly to be se-
dative and diaphoretic, and it is said that the sweat they excite by
a single dose may continue for twenty-four hours without  languor
or debility.  As a medicine, these  oils  have perhaps  been thrown
aside  too hastily.
  Whatever be the relaxant or sudorific employed, it  should be as-
sisted by plentiful potations of  warm  diluents, and by placing the
patient  between  the  blankets instead  of  in the sheets of his  bed:
for I have already had occasion to observe that upon  these auxilia-
ry means depend, in many instances,  the accomplishment  of the
object we have in  view, without which the most urgent diaphore-
tic exerts itself to no purpose.
  The most important season, nevertheless, for medical operation,
is in  the intermission of the  paroxysms : since, howev er  success-
ful we may be in moderating  the  febrile attack, it is  rarely  that
we can  depend upon any plan which may then be adopted to pre-
vent a recurrence  of the fit.
  The opinion of mankind seems to have concurred  in most ages
in regarding debility as either the proximate or predisponent cause
of intermittents, since  almost the  only medicines that have  been
brought forward to guard against the  recurrence of their periodic
attacks  have been tonics, with the sensible quality of bitterness or
astringency, or of  both.
  In what way these act upon the moving fibre at any time, and
particularly  in  the  disease  before us,  we cannot  say with' any
degree  of precision.  The tone  of the  moving fibre depends  un-
questionably in some degree upon the state of the fibrous material
itself, but perhaps in a much  greater  degree  upon the quantity or
quality  of the nervous fluid that issues  from the brain and is com
mumcated  to the fibrous  structure, or as it is modified in any par-
* Edinb. Med. Comment. Vol. vi. p. 359. 
GE. II.-SP. V.]     SANGUINEOUS FUNCTION.
81
 ticular set of fibres.  We have  great reason for  believing  that as-
 tringents, in producing tone, act upon  the fibrous material itself,
 for  we find them operating in a like manner upon  animal fibres
 both in a living and a dead  condition.   But whether, as  Dr. Cullen
 conjectures, it be the part of bitters alone  to act upon the  nervous
 power or living principle which adheres to them, and especially in
 the  very singular  manner in which he represents them as acting,
 is a different question;  and the  present is not the  place  for  enter-
 ing upon it.
   If we contemplate the  nervous fluid as a peculiar secretion,  and
 the brain as the secreting organ, we can readily conceive  that the
 component  parts of this organ as well  as of any other, may be invi-
 gorated by  medicines  that  have a peculiar influence  on its struc-
 ture, and probably concentrate  and give tension to its  fibres;  and
 that, in consequence hereof, it may be rendered capable of secret-
 ing its proper fluid in greater abundance, or a more elaborate per-
 fection.  And  we  can also  readily conceive  that such effects may
 be produced by both bitters and astringents, as well as by medi-
 cines that possess  some other sensible qualities, though these are
 the most obvious in their operation.   But  should we,  with  Dr. Cul-
 len, affirm that the same  bitter  employed  in the same  proportion,
 produces both tone and  atony,  energy and debility ; that it both
 cures the gout, and occasions it; that  employed for a certain time
 it effects the former,  and after  such time,  the latter ;  and should
 we beyond  this affirm, with  him also,  that  the nervous fluid is not
 a secretion,  but an inherent power of the  brain ; that it admits
 neither of  increase, nor diminution ;  is changeable in its state, but
 unchangeable  in its essence ;  becomes excited and  collapsed, or
 rises and falls in its energy,  but experiences  nothing of the decom-
 position or  recruit of every other part of the living frame around
 it; we should  travel into a labyrinth of incongruities,  and  only en-
 lighten ourselves with a will-o'-the-wisp.   Dr. Cullen's system,  like
 himself, is  a work of no ordinary stamp ;  it is full of immortality,
 but mixed up with weak and perishable materials.
   Of the remedies appertaining to the one or the other of the  two
 divisions we are now considering,  those of astringents and bitters,
 the  cinchona or Peruvian bark,  which unites both qualities in itself,
 is on every account entitled to our first attention.
   This valuable medicine, which some practitioners are apt to des-
 pise or think lightly of in the present day,  has never  been altoge-
 ther without its opponents ; and there are  many facts respecting its
 operation, which, if not altogether anomalous, are of very  difficult
 solution.
   Peruvian bark,  according to  the authority of Don Joseph  Ville-
 robel, a Spanish  physician  noticed by Badus, was  first  brought to
 Spain in the year 1632; but here, as in every other country, it had for
 a long series of years to encounter the prejudices of the medical pro-
fession; and  consequently was very rarely made use of, and unques-
 tionably would have sunk into  oblivion but for the activity of  the
   VOL.  II.              11 
32                       H^MATICA.           [CL. IH.-OR- *<

Spanish Jesuits,  who continued zealously to recommend it, and to
import large quantities of it from their brethren in South America.
Through these means it was at last recommended by Pope Innocent A.
in 1661, as a medicine perfectly innocuous and salutary : and a bcbe-
dula Romana,  drawn up under the sanction of the  physician to bis
holiness, pointed out in express terms the  time  and proportion in
which the bark was to be taken.  Unfortunately the time stated was
frigorc febrili incipiente,  " at the  commencement of the  cold  fit;
and it being administered in this manner with only temporary be-
nefit to the Archduke Leopold of Austria, a year or two afterwards, it
immediately fell into great  discredit with a very  large  and  learned
part of the medical community  of Europe ;  and a most acrimonious
warfare was instantly  waged in every quarter on the subject,  in
which the combatants on both sides seemed more desirous of victory
than of truth.
  In our own country the bark began to become popular about 1655.
In 1658, Mr. Underwood, an  Alderman of the  city of London,  died
while using it, and was instantly reported to have  fallen a sacrifice
lo its power; and so prejudicial was the effect of this rumour, that
Cromwell, who was attacked with an ague in the same  year, was
suffered to languish and at length  die without an exhibition of the
bark, his physicians being afraid to make a trial of it, in consequence
of the fatal accidents that had so lately accompanied its use : in the
words of Morton, " nondum vires corticis in hoc  veneno subigendo,.
saltern hie loci, comprobata? erant"*
   In England, therefore, as well as on the continent,  there was a
great conflict of opinion. Dr. Prejean, who both preceded and suc-
ceeded  Dr. Harvey as President  of the College of Physicians, ap-
pears openly to have  advocated its employment  in 1658, according
to facts adverted to by Sir George Baker in his admirable article on
intermittent fevers,! from which these hints are chiefly  drawn up.
Dr. Brady, professor  of physic at Cambridge,  appears  equally to
have countenanced it; as does Dr. Willis according to his own
statement; while Dr. Morton professed himself inexperienced  upon
its virtues, and Dr. Sydenham was decidedly adverse to its  use.
   Sydenham,  however,  was a man of reason and liberality.   His
prejudices, and especially  those derived from the hypothesis that a
fever is a fermentation  in the  blood  raised by nature  to throw off
some peccant matter at the surface, and which ought not therefore
to be checked in its course, however  wise it may be to moderate it
in its violence,  were all at arms  against the use of the bark under
 any circumstances: and the mischievous effects to  which  he had
 been an  eye-witness in some  instances, and its  total inertness in
 more,  gave a sanction  to suspicion, if it did not justify hostility-
 But he was determined to watch  it for a still longer period through
 all its variable  effects, and to  abide by the result  when  fairly cast
*' Pyrctolog. p. 17.
t Medical Transactions, Vol. m. Art. xiil 
13E. II.-SP. V.]      SANGUINEOUS FUNCTION.                83

up.  He soon became sensible that it was, in most cases, a powerful
engine ; that in many instances it was highly serviceable ;  and that
in those in which it failed, the miscarriage was rather to be ascribed
to some  error in handling it, than to a want of power in the drug
itself.
   Sydenham had sufficient  ground for this  last conclusion.  The
mode  in which it was, at this time, usually  administered,  was in
doses of two drachms given  twice in the twenty-four hours; and, as
already observed, the time selected  for the purpose was during the
existence of the paroxysm.   It is moreover  highly probable that it
was sometimes considerably adulterated, from the difficulty of obtain-
ing it  in any considerable quantity.
   In 1658, we  learn from Sturmius, who warmly patronized its use,
that pure bark was so scarce on the continent, that twenty doses of
the powder were sold at Brussels for sixty florins for the purpose of
being sent to Paris; and that this order so completely exhausted the
apothecary's stock,  that he himself  was incapable of obtaining any
even at that  price.  And hence, for the use of Gne patient, who
was attacked  with an  obstinate  intermittent fever in the  month of
February ef the same year, he  was obliged to wait  till the  June
following before he could obtain a supply.*   Nor  was it less diffi-
cult to be procured at Brussels than in many other parts of Europe ;
for Bartholine, then residing at Copenhagen,  having received as a
great rarity a present of three doses, or six drachms, of the powder,
from some friends who had  brought it from Italy, was induced to
make  a trial of it on a lady who had a quartan fever.  Of this small
portion the first dose or two drachms was rejected from the  patient's
stomach; and, in order to prevent a  repetition of this accident, and
consequently the loss of his entire stock, the administrator  macera-
ted his two remaining  doses in wine for forty hours,  and gave the
infusion during two successive paroxysms.   The only effect was, that
the fever was changed from a double to a single quartan.  And here
the experimenter was obliged to stop,  as  having no more materials
to proceed with.t  But even in 1678,  when the same pretext for
sophisticating it no longer existed, Morton complains that the bark
offered for sale was become so inert, corrupt, and adulterated, that
it was  necessary to increase the proportion from  two drachms, to
one, two, or even three ounces for a single dose.  And, thus given
by wholesale,  we cannot wonder that still more  mischief should re-
sult from its abundance than from its scarcity,  whatever might be
the purity or impurity of its quality.
  To  guard against all the evils that seemed to accompany its use,
Sydenham proposed to himself the following regulations.
  Firstly, To be peculiarly  cautious in the  quality of the  bark he
employed; and to allow of no intermixture,  whether from  fraud or
a view of increasing its virtue.
* Febrifugi Peruvian! Vindiciarum Pars prior, p. 84. Antwerp, 1659.
i Thomrc Bartholin! Hist. Anat. et Med. Cent. v. Hist. L. Hafnioe, 1661. 
84                       h*matica.            [cl. iil-oh. '

  Secondly, To administer the bark in the intervals, instead of in
the paroxysms of a fever.                                    .
  Thirdly, To give it after the  rate of two scruples every  lour
hours,  instead of two drachms  twice a-day after the Schedula Ko-
mana.                                               .     -..  ,
  Under these regulations the bark seems to have  acquired all tne
success to which it has at any time pretended; and modern practice
has added little to their value.
  The  most  important of them is that which effected a change in
the period of exhibiting the bark.  But whether the  merit of first
suggesting this improvement be due to Sydenham,  or to some  con-
temporary of his, we cannot at present very accurately determine.
He is, indeed, the only person who  openly lays a claim to it, and
asserts that he was led to this alteration  after deeply  pondering the
subject—diu multumque apud se agebat: yet Morton who published
his Pyretologia in  1692, only three  years after the death of Syden-
ham,  asserts,  somewhat loosely indeed, that during twenty or five
and twenf^ years* he had been in the habit of giving this antidote,
as he calls it, in every season of the year, and to persons of all  ages
and constitutions; that he had cured every species of intermittent
with it  quickly and radically;  and had found it more expedient to
give it  in the intervals  than in the fits.  While  Lister, who was
contemporary with both Sydenham and Morton, and who treats nei-
ther of them  with respect,  directly  accuses Sydenham, a few years
after his death,  of having copied his mode of giving the bark from
the miserable mountebank Talbor, who was its inventor ;—auctore
suo, misero  illo agyrta.  Talbor.t  Talbor or  Tabor,  however, is
scarcely open to the stigma of being a mountebank.  He concealed,
indeed, his preparation of the bark, but he had been regularly ini-
tiated into a knowledge of medicine  by an apprenticeship to an
apothecary at Cambridge ; was the most successful,  and therefore
the most popular employer of the bark in his day;  acquired a high-
er reputation in this line of practice  than any  other  individual
whatever; was appointed one of the physicians to Charles II. against
all the  influence of the College ; was specially sent for to Paris to
take  the Dauphin under his care  ; succeeded in  curing him; and
afterwards divulged his arcanum for a stipulated sum to Lewis XIV.
   Still, however, under whatever form, in whatever quantity, and
at whatever  time the bark is given, it is not found to be a specific,
not only in every individual, but  in every intermittent; and we are
hence  again driven  to  a  principle  I  have already ventured to lay
 down, that intermittents of all kinds  are occasionally influenced in
 their character by idiosyncrasies or the temperament of the atmos-
 phere.  And it is  hence of considerable importance to know  what
 other medicines have  the strongest claim to attention, when, from
 accidental circumstances, the best fails of its common effect.
* Pa. 114, 132.

r M. Lister Octo Exercitationes Medicinales de Cort. Peruv. exhibendi tempore. 
GE. II.-SP. V.]        SANGUINEOUS  FUNCTION.             85

  This, as we have already had  occasion to observe, was the case
in the singular intermittents that prevailed  both  in this  metropolis
and in the country in the year 1787, in which the bark  seemed to
have no energy whatever, notwithstanding that its genuineness was
sufficiently tested and proved.   In consequence of which the febri-
fuge powers of various  other medicines were attentively  studied
and appreciated.   In  some instances other medicines were mixed
with the  bark,  and seemed  to  a certain extent to  call forth its
proper power : a mixture of bark and alum answered in some cases,
but produced disappointment in others.  " The crude sal ammoniac,"
says Dr.  Petrie, who was physician to the  hospital at Lincoln,
*' had not a more certain effect.  Several women  were cured  in an
hospital by what is called the Dutch remedy for  an ague ; which is
compounded of the bark and  cream of tartar, each two ounces, and
sixty cloves powdered.   A drachm and a half of this powder was
taken every third hour.   Yet this likewise frequently failed.  We
at last thought  that we  had fallen on a specific  in  the  powder  of
bay-leaves,  plucked from the tree and dried in the shade.  It was
given from one  to two  scruples in  the  beginning of the  cold fit.
This powder was very  efficacious  in  preventing the fits in  many
cases, where the bark, in the  largest quantity, had been unsuccessful.
But almost all who used it had a relapse in  the space of  a fortnight,
three weeks, or a month. One patient, just at the time the fit was
expected, took sixty drops of the Thebaic tincture.  On  this he fell
into a profound sleep, sweated profusely, and escaped the fever, not
only then but at two successive periods.   Eight quartans in the
hospital,  and four in private  practice,  were entirely cured by one
drachm of the theriaca andromachi, the same of the root of calamus
aromaticus  in  powder, and fifteen grains  of salt of tartar.  This
mixture was taken in warm ale  or wine-and-water, an hour or two
before the fit.—Nevertheless I must confess that I met with several
cases where no  medicine prevailed ; and many  patients despairing
of  relief left themselves to nature; some of whom went into  a
pulmonary  consumption, jaundice,  or dropsy.    Many, whom  I
thought cured of  quartans,  lately  relapsed.  I  have now on the
hospital books four patients, ill of quartan fevers,  who have received
no benefit; and I have no hope left but in a  long course of deob-
 struent bitters,  and tinctura  sacra, aided by the  approaching sum-
 mer."*
   Morton's  medicine, of one  scruple of  chamomile flowers, ten
 grains of salt of wormwood,  and the same quantity1 of calx of anti-
 mony,  given every  sixth hour, is  said to have subdued, in the
 metropolis, an obstinate tertian in two instances.   And Dr. Heberden
 found that two drachms of the powder of myrrh, taken just before
 the time of the expected fit,  relieved a patient from an  ague  which
 for a long time  had resisted the power of the  bark, though  taken in
 very large quantities.
*■ Med. Transact. Vol. in. p. 165. 
86                      HiEMATICA.            [CL. HI.-OR.  I.
   The red-bark was now also tried for the first time :  it was proved
 to be of unquestionably  superior virtue to  that in common  use ;
 but even a moderate dose of it so often oppressed the stomach and
 excited nausea and vomiting, probably produced by  its containing a
 larger proportion of resin, that, writing at  this very  period, Sir
 George Baker tells us, « I have for some time avoided the use of it.
   Arsenic was also tried in combination with opium.   It is admitted
 that it often  effected a cure;  but  was frequently productive ol
 violent vomitings, colic, and dysentery.   It seems however to  have
 been given at this period in a somewhat rude and unscientific form.
 " Arsenic,"  says the distinguished writer whom I have just cited,
 "is  mentioned in books  as  a febrifuge,  but  it is one  of  those
 substances of which we are not as yet so far masters,  as to be  able,
 by any art, to  render it transferable from the list of poisons to our
 Materia Medica;  and it cannot  be deemed to be a proper remedy
 for an intermittent fever whilst an intermittent  fever  is less formi-
 dable  than arsenic."   But to this substance we shall  have to return
 presently.
  If the praxis, therefore, frequently failed which was in use about
half a century ago, it was by no means for want of  distinguished
 abilities, great diversity of means, or an  ample field for experi-
ment.  And, although a few other medicines  have since been sub-
mitted to trial, or some  few of the same in improved forms,  I am
 afraid we have no great reason to boast of much  clearer illumination
 or superior success in our own day.                           *
  We may not, indeed,  be disposed to encourage the farther  trial
 of such operose preparations as milk boiled just seventy-seven times
 over,* which  was one  of the most  popular  charms of the above
 period; but  I have heard of several remedies in high favour and in
 common use among ourselves, which have as  little claim to distinc-
 tion.
  The chief bitters that have been called into requisition, indepen-
 dently of those already noticed, are, gentian,  cascarilla,  willow-
 bark, nux vomica,  and the  leaves of the cherry-bay, or prunus
 lauro-cerasus:  the chief astringents, tormentil,  galls and oak-bark ;
 the bark of  both species of the swietenia or mahogany tree ; avens
 or caryophyllata  (the  geum  urbanum Linn.,)  alum,  and several of
 the metallic oxydes.
   To all these a common remark may be applied, that, where  they
 have  been of real  service, it has generally, though  not  in every
 instance, seemed*to arise from their  uniting the two qualities of a
 bitter and an astringent, and that they have rarely answered where
 there has been only one of these qualities to depend  upon.  Thus
 tormentil, one of the most powerful vegetable  astringents  we pos-
 sess, and gentian one  of our  most powerful vegetable bitters, suc-
 ceed so rarely alone, that no  dependance is to be placed upon them;
 but  when given  in  combination, they  almost  rival the virtue  of
Ephem, Nat. Cur. Dec. m. Ann. vn. vin. Obs. 48. 
GE. II.-SP. V.]        SANGUINEOUS FUNCTION.              87

cinchona ; and have  occasionally succeeded where the latter has
failed.   " Joined,"  says Dr.  Cullen, " with  galls or tormentil, in
equal parts,  and given in sufficient quantity,  gentian has not failed
in any intermittents of this country in which I have tried it."*
   There is,  however, a principle  independently of bitterness  and
astringency, that seems absolutely necessary to enter into conjanc-
lion  with these, in order to  give full efficacy to any medjcine
employed as  a febrifuge  in intermittents;  and a principle  that has
hitherto eluded  all research.   For if the cure depended upon the
intensity of a bitter and an astringent quality alone, galls, oak-bark,
and mahogany-bark ought to succeed better, not only than an union
of tormentil  and gentian, or chamomile and alum, which have  also
been found very serviceable, but trrtm cinchona itself; which every
one  knows they do not do;  although, when Peruvian bark cannot
be obtained,  they become desirable substitutes.
   The  nux vomica, and Ignatius's bean (strychnos nvx  vomica, and
ignatia arnara, Linn.,) combine, with an intense bitter, a most active
narcotic virtue  ; and how far the last may be peculiarly opposed to
a recurrence of that spasm on the extreme vessels which constitutes
the  cold fit,  it is difficult to determine.   M. Bourieut from his own
practice strongly recommends the latter, and PaulliniJ and  Aaskow§
the  former.   If Dr. Fouquier's remark be well founded, which we
shall have occasion to notice more at large  when treating of para-
lysis, that these poisons have a power of augmenting energy in de-
bilitated muscular fibres,  while they leave those in health unaffect-
 ed,  we can account for some part of the success  which has been so
 vauntingly  ascribed  to  them in the case  of  intermittents.   But,
notwithstanding that they have been for this purpose before  the
public  for upwards of a century, the infrequency of their use is a
strong  argument that they are not  much entitled to commendation,
" In a very small  dose," says  Dr.  Cullen, " the  faba Sancti  Ignatii
has  the effect  of curing intermittent fevers."|[   But  whether he
reports this from his  own practice, or from that  of others, we can-
 not  exactly determine :  nor does he tell  us  what is the small  dose
 he refers to.  I have tried the nux vomica to the extent of eight
 grains  in powder every six hours for an adult under palsy, without
 any mischievous effects  except a slight stupor in the  head.  And
 much  beyond this we cannot proceed with  prudence.   Hoffman
 gives the case of a girl of ten years of age, who was killed by taking
 fifteen  grains of it, divided into two doses, for an  obstinate quartan.1l
   The lauro-cerasus  was at one time,  as we are told by Dr.  Brown
 Langrish, a common medicine in his neighbourhood for the cure of
* Mat. Med. Part n. Cl>. n. p. 72.
t Hist, de la Societe R. de Med. 1776. p. 340.
X Com. m. Obs. 45.
I Act. Societ. Med. Hafn. Tom. n.
|| Mat. Med. Part ii. Chap. n. p. 76.
* Philos. Corp. Hum. Morb. P. u. Cap. vm. 
88
HjEMATICA.
[CL. III.-OR. I.
 agues :* but he takes no notice of the dose or mode of administering
 it.   Its properties are nearly the same as those of bitter almonds ;
 and Dr. Bergius informs us,  that he  has frequently prescribed  an
 emulsion of bitter almonds with success in intermittents,  in  the
 quantity of a pint or two daily during  the intermission ;  and that  it
 has sometimes cured where the bark had failed.t  This is an autho-
 rity worth attending to;  and as the same medicines are said to have
 a peculiar power of resolving visceral  obstructions, they have  an
 additional claim to a cautious series of experiments.   It is generally
 supposed, in the  present day, that their poisonous property depends
upon their containing a portion  of native prussic acid : the taste of
prussic  acid, however, is not bitter,  but  sweetish and acrid.  Yet  it
is chiefly the bitter we seem t» want in the present instance ; and
if prussic acid really exist in others, and could be separated from the
bitter principle from which it appears to be distinct, we might be
put into possession of a medicine of considerable importance.
  The  only metallic oxide really worthy of notice is that of arsen-
ic ;  for  although various  oxydes of iron,  mercury, zinc, and copper,
have  been  tried, and occasionally  extolled, none of them have
proved  so decidedly beneficial as to  render it  worth while  to try
them over again.
  Arsenic, under  various forms, has been employed from a very
early period.J  It is, strictly speaking,  an  oriental  medicine,  and
has been in vogue immemorially in India, and indeed, all over the
east, as  a most powerful alterant, as we shall have occasion to no-
tice more at large when  treating of  syphilis and  elephantiasis.   It
was probably introduced  into European practice  by the medical
students under the brilliant caliphate at Bagdad: and seems to have
been first appropriated to the  cure of  intermittents by  the Jewish
physicians of Poland.§  In Sir George Baker's time, we have seen
already that it was in extensive  use, but productive of such very
different results, that, however successful it might prove occasion-
ally, this distinguished pathologist thought it a worse evil  than any
ague whatever.   At that period, however, it does notappear to have
been tried in its most commodious forms, which are" those of an ar-
senite or arseniate of potash.  * M. Macquer recommends the  latter;
 Dr. Fowler, many years ago introduced and gave abundant proof of
 the utility  and general commodiousness  of the  former;  and under
 this modification  it has at length found its way  into the  Pharmaco-
 poeia of the London College, under the name of liquor arsenicalis.
  The  cases of success from the use of this medicine are so  nume-
 rous, and its employment is now become so general, as to render it
 unnecessary to advert to particular authorities  in proof of its febri-

  * Experiments on  Brutes.  See also Phil. Trans. No. 418, 420.
  t  Mat. Med. p. 412.
  X Act. .Med. Berol. Dec. i. Tom. m.
 hJh;Slbep.t' A.dverTsar' Pract« Prim.-Slevogt, Pi. de  permission Prohib. et pro-
 nib' jone Perimss. Jen. 1700. 
GE. II.-SP. V.]        SANGUINEOUS FUNCTION.              89

fugal power.   With many constitutions  there can be no question
that it disagrees very  considerably;  and there are  numerous  in-
stances of its  failure :  but it is a medicine of  real and inappreciable
value in many diseases, and in none more than  in intermitting fe-
vers.   Dr. Fowler advises  it to  be taken in  doses of from two to
twelve drops, according to  the age and strength of the patient, once,
twice, or oftener, in the course  of the day:  and  the  directions are
go  broad,  and at  the same time so much  within limit, that no*
actual harm can occur from following them literally.   It will, how-
ever, often be found advantageous to  combine a few drops of tinc-
ture of opium with each dose,  to guard  against the vomiting and
griping which it is sometimes apt to excite ;  and the  bowels should
be kept open by warm aperients during its use.   Under the French
Directory, a similar preparation of arsenic formed a part of the po-
litical constitution of the day ;  for an edict was formerly published,
commanding that the surgeons of the army of Italy should,  within
the course of two or three days, cure the vast  number  of soldiers
suffering  from agues  caught in the marshes of Lombardy, by the use
of this medicine, under pain of military punishment.
   The result of this general survey is, that the cinchona  offers by
 far the best  remedy for intermittents of every kind;  that arsenic is
 its best substitute; and that where these fail, as fail they will occa-
 sionally,  or particular circumstances  should prohibit  their use, we
 must throw  ourselves upon such other  medicines  as  unite  intrinsi-
 cally, or  by  combination, a bitter and an astringent principle with a
 certajn proportion of aroma or stimulant warmth.
    It is at  the same time clear that a  bitter and  astringent principle
 are, not the only, nor even the  most  effectual qualities for the cure
 of an intermittent; for the arsenical  preparations  contain  neither
 of these  in  any  prominent degree ;  while, as already observed,
 there are many medicines that possess them in far greater abundance
 than the  bark, which have no claim  to be put in competition with it
 as a febrifuge.  In effect,  of the three  species of cinchona used offi-
 cinally in the  present day, the lance-leaved, pale or quilled bark
 (c. lancifolia,) heart-leaved or yellow bark (c. cordifolia,) and oblong-
 leaved or red bark (c. oblongifolia,)  the yellow, which, as we learn
 from Mutis and Zea, is the genuine  febrifuge of Spanish America,
 and whose superiority to the rest has  been abundantly proved in
 this country as well as on  the continent of Europe, is very conside-
 rably less bitter and astringent than  the red, and  not more  so than
 the pale bark: it has less resin than the first,and less gum than the
 second.   Dr. Cullen preferred the  red, but Zea's  communications
 upon the subject* were not then published; and he was not in pos-
 session of the experiments by which the statement of the latter has
 been confirmed.  Sir George Baker, as already noticed, found the
 red bark produce so much oppression and nausea that he was obliged
 to discontinue its use.
   * Annal. de Hist. Nat. Tom. II. Madrid, 1800.
voj>. n.              12 
  90                       REMATICA.             [CL» in--0R' h

    In administering the bark, little needs to be added  to  the rules
  laid down by Sydenham, and copied in  a preceding page.   VT.
  Home has sufficiently shown, not only that the best time for com-
  mencing the medicine is soon after the paroxysm, but that it should
  be discontinued some time before a recurrence of the cold fit, since,
  if persevered in till its accession, this fit  is  almost  uniformly  ren-
  dered more violent*
»  If in the proportion of half a drachm or two scruples to a dose,
  as recommended by Dr. Sydenham, or such other quantity  as  may-
  sit without uneasiness on the stomach, it should not succeed, it
 should be tried in combination with some aromatic, or omitted  alto-
 gether ; and by no means be increased to  the enormous  quantities
 some  practitioners have  ventured  upon, who seem to have  con-
 ceived that they could force the system to yield  to its powers by
 the overbearing arms of weight and  measure.   It is  singular  that
 Borsieri should have so far lost sight  of moderation, as to have  pre-
 scribed occasionally from four to six  drachms of  the  powder  in a
 single draught.  In the extremity of  the  yellow  fever such doses
 have, indeed, been given, and perhaps with  advantage,  but opium
 and old port, in  large  abundance,  have been given at the same
 time.
   It will also be judicious to abstain  from the use of bark in every
 instance in which  any of the abdominal viscera appear to be labour-
 ing under parabysmic enlargements, whether antecedently to its
 employment or during its use;  and, in  these  cases,  to alternate
 small doses of calomel, with whatever tonic may be found to agree
 best with the system.
   Among the  endemic intermittents  of the present day that  are
 more particularly  worthy of notice, are those which appear in  the
 neighbourhood of Rome,  and especially about the  Pontine marshes,
 which have often  been drained to carry off the decomposing animal
 and vegetable materials that spread their aria cattiva, as it is called,
 over the whole  of the Campagna.   The disease hence  produced
 is named, from its source, malaria.  It is also found in like situa-
 tions, and has the  same name, about  Syracuse, and  other parts of
 Sicily.   M. Rig'and de l'lsle has asserted, that the miasmic particles
 which infect the air in these places are heavier  than the air in its
 loftier and lighter strata, and may be  separated from it.  He  tells
 us that he  has found an elevation of 300 yards, at the Pontine
 marshes themselves,  a complete  security  from  infection;  and he
 proposes for those  who  reside lower to  sift the air which they
 breathe, by wearing a fine silk gauze over the mouth and nostrils.t
* Clinical Experiments, 8vo. Edinb. 1780.
t Mem. de l'lnstitut. Royal de France, March 24, 1817. 
GE. III.-SP I.]       SANGUINEOUS  FUNCTION.                91


                     GENUS  III.


                       EPANETUS.

                     Hemtttent iPe&er.

 SYMPTOMS  STRIKINGLY EXACERBATING AND REMITTING; BUT WITHOUT  IN-
       TERMISSION ;  ONE PAROXYSM EVERY  TWENTY-FOUR HOURS.

 This genus offers the three following species, which will be found
 sufficient distinguished from  each  other by their specific  charac-
 ters :

 1. EPANETUS MITIS.             MILD REMITTENT.
 g________MAL1GNUS.         MALIGNANT REMITTENT.
 3.________HECT1CA.          HECTIC FEVER.

    In the last, the remission is perhaps more perfect than in either
 of the others; and it serves to show how little foundation there is
 for referring  all remittent as well  as all  intermittent fevers to  the
 individual cause of marsh-miasm:  for it would be difficult,  though,
 perhaps, not impossible, to find a single example of a genuine  hec-
 tic originating from this  source.   Marsh-miasm, however, is  the
 most common cause  of  the  second, perhaps  of the first species;
 though we shall presently find it probable that even here, and par-
 ticularly in the second species, human contagion has also occasion-
 ally proved a  cause, as it assuredly has in those cases of hectic fe-
 ver produced  by perpetually attending upon or sleeping with a con-
 sumptive patient.
                        SPECIES I.

                  EPANETUS MITIS.

                     JtttUi lUtmttent.

PULSE REGULAR THOUGH FREQUENT;  DEBILITY SLIGHT; REMISSION  DIS-
        TINGUISHED BY SWEATING OR A CLOUD IN THE URINE.

This  species occurs most  frequently among persons of  relaxed
fibres, debilitated habits, and sedentary occupations;  and is usually
preceded by an irregular action of the alvine canal, flatulency,  ab-
dominal tension, dyspepsy, or some other affection of the viscera of
the lower belly.  It occurs at ail seasons of the year, but more fre-. 
92
HjEMATICA.
[CL. IH.-OR. I*
 quently in the autumn ; the ordinary temperament of the  season
 uniting with the  patient's infirm state of health, aud thus  adding an
 exciting to a predisponent cause.  Fatigue, cold, or long  exposure
 to the rays of the sun, are also, at this time, powerful concomitants,
 and quicken  the  appearance of a disease, the seeds of which have tor
 some time, perhaps, been lurking in the system.
   The patient complains of drowsiness, and feels languid ; is occa-
 sionally chilly, and afterwards flushed, but without perspiration ; tor
 the  skin is hot and dry, the thirst considerable, commonly with nau-
 sea  and a total loss of appetite.   In the course of the day,  but usual-
 ly towards the evening the pulse  quickens, the  heat increases,  and
 at length terminates in a sweat, which, however, is sometimes only
 partial, rarely free and copious, and never critical: for, on its ceasr
 ing, the skin  is still dry and  heated, and the pulse accelerated.
 Sometimes the exacerbation occurs about noon, and  sometimes in
 the  middle of the night.
   If the disease be left to itself, the symptoms augment in severity
 daily : the head occasionally, but more generally the liver, or some
 other abdominal  viscus, gives proof of being loaded and oppressed,
 and  the restlessness is intolerable ; or a sudden cholera supervenes,
 and  carries off the complaint by a salutary crisis.
   This species seems to be primarily dependent upon torpitude, or
 obstruction  in some  one or more of the chylopoetic organs,  and
 generally yields  to a course of active purgatives,  amongst  which
 calomel ought to take the lead.   These should be  repeated  two or
 three times a week, and the intervals be filled up with mild diapho-
 retics.  The pulse will generally  be found from  ninety to  a hun-
 dred strokes  in a minute; but as  soon as it sinks  below this,  and
 the  heat and dryness of the skin have yielded to a  general softness, •
 columbo alone,  or combined with sulphuric acid,  will easily com-
 plete the cure; though the disease not unfrequently runs on  for ten
 days or a fortnight.
   The remittent fever of infancy, which is  generally ascribed to
 worms,  does not  essentially differ from the present,  regard being
 had to the greater irritability  of the moving fibre in early life.
 Worms, there can be no doubt, are sometimes the  cause of this in-
- fantile fever, but perhaps rarely; and there is no instance on re-
 cord of their having been traced in  the bodies of those  who have
 fallen victims to it.  Dr.  Hunter, indeed,  expressly  declares that
 he has often searched in vain.  The  ordinary cause is, crude accu-
 mulations in the first passages, whence the digestion proceeds im-
 perfectly ; there is great  general irritation, with considerable lan-
 guor ; the belly  becomes tumid and  often  full of pain ;  the  food is
 nauseated;  the head is hot, heavy, and often comatose ;  as  though
 there were water in the ventricles,  which is sometimes suspected
 though without foundation; the skin is pale or livid with occasional
 flushes in the cheeks.  It is a singular fact, that if the exacerbation
 or increase of fever take place  in the night, there is wakefulness
 -and perpetual jactitation; if in the day-time, drowsiness and  stupor. 
GE. III.-SP. I.]     SANGUINEOUS  FUNCTION.
93
  Dr.  Butter recommends, as an aperient, small doses of neutral
salts, and, when the bowels have been  opened, nitrate of  potash;
or,  if  there be  considerable irritation, the  extract of hemlock.
Generally speaking, however, there is such a sluggishness in the
peristaltic  action of the bowels, as well  as in the intestinal secer-
nents, that neutral salts will not answer the purpose ; and, in conse-
quence, rather  add to the  irritation than carry it off.  And hence,
much  stronger purgatives should  be employed  from the first;  as
calomel, resin of jalap,  or gamboge dissolved  in milk ;  and it may
safely be prognosticated, that, till this plan is  had recourse to,  the
disease will in most instances maintain its ground if it do not make
a fearful advance.  But with  a course of  brisk  cathartics, in con-
junction  with perfect  quiet, good ventilation, and  light nutritive
food, it will usually give way in a week or  a fortnight.
                         SPECIES  II.

               EPANETUS  MALIGNUS.

                  ^Malignant Remittent.

PULSE SMALL,  HURRIED,  IRREGULAR; DEBILITY EXTREME;  OFTEN WITH
                     SIGNS OF PUTRESCENCY.

Extreme debility  may  be inferred from  the  symptoms  of great
weakness  and irregularity of the  voluntary motions;  weakness of
sensation ; weakness, and wandering of the mind ; weakness of the
pulse and of respiration; coldness and shrinking  of the  extremi-
ties ; and a tendency to faint in an erect posture; nausea, vomiting,
and a total disinclination  to  nourishment;  difficult deglutition, de-
pending upon an atony  of the muscles of  the fauces;  involuntary
excretions, depending upon an atony or paresis  of the sphincters.
  A putrescent state of the fluids  may be determined from the fol-
lowing symptoms : pulse quick and tremulous;  heat  of the surface
sharp and pungent, giving to  the finger a peculiar tingling  for some
minutes afterward ; the skin  parched, or soaked with sordid,  fetid
sweat; the smell  offensive to a considerable distance ; the breath
hot and fetid; the mouth aphthous; the tongue clammy, fetid, livid,
greenish-black ; the lips swollen,  puckered, cracked,  and purple ;
the urine brown  or blackish,  and  offensive ; black discharge often
in profuse quantity from the stomach;  the  stools blackish,  colliqua-
tive, very  offensive, parted  with profusely  and insensibly;  the
mind wandering ; twitching of the tendons ; swelling and tension of
the belly ; petechial spots, vibices,  and hemorrhages from diffe-
rent parts, without proofs of increased impetus.
  This species may be  traced under four varieties, each sufficient-
ly marked by its own symptoms. 
94                      H^MATICA.            [CL. III.-OR. I-
       «  Autumnalis.             Autumnal Remittent.
       £  Flavus.                 Yellow Fever.
       y  Ardens.                 Burning Remittent.
       I Asthenicus.              Asthenic Remittent.

   The autumnal remittent is that which  so frequently shows itself
 in our own country, in the season from which it derives its name,
 with a strong tendency to assume  the tertian or  double tertian
 type :  or, in other words, with striking exacerbations every other
 day, or,  where the double tertian is  imitated, every day, the ex-
 acerbations commencing  at noon, and the duration  being usually
 under  twelve hours ; the intervals consisting of remissions, which,
 however, are  not  always very clearly determined.  Where the
 double tertian type prevails, and the patient has to labour with two
 distinct sets of tertian exacerbations,  it is  obvious that one of these
 must take place every day, as  it must occur in the remission of the
 other.  And  this variety is, in  consequence, often  mistaken for a
 quotidian  remittent.  But a little attention will point out the real
nature of the disease.   For while the one set will  usually be found
 distinguished from the other by evincing some difference in its du-
ration or its violence, both will be distinguished from the quotidian
by the time of their attack, which is at noon,  while  the  quotidian
 attacks in  the morning; and by the comparative brevity  of the pa-
roxysm, which is always under twelve hours, while that of the quo-
tidian runs on towards  eighteen.
  The perfect apyrexy which takes  place  in the interval of inter-
mittent fevers gives the constitution a full power of recovering its
energy and recruiting its sensorial supply; and we have hence ob-
served, that  there is great difficulty in accounting for  a return of
the  paroxysm:  I mean in  cases in  which the patient is removed
from the  miasmic atmosphere ;  for  otherwise  the cause that com-
menced the disease will be present to continue it.  Habit may pos-
sibly effect this  after a recurrence of several  paroxysms; but this
will  scarcely apply to the second, in  which no habit can with great
strictness of language  be said  to  have  taken  place.   In remittent
fevers, however, something of this  difficulty is removed,  for the
constitution  even during the remissive interval, is still  struggling
with disease, and has not an opportunity of recovering its sensorial
power.
  There is no perplexity  in accounting for a  greater tendency to
febrile affections towards the autumn than in any other  quarter of
 the year;  and this whether we  allow the operation of a specific
 febrile miasm from marshes or not.   When the animal  frame has
 for some  months been exposed  to  the stimulus of a high atmo-
 spheric temperature, and not  unfrequently perhaps to  that of the
 direct rays of the sun, all its organs become relaxed and debilitated.
 The sensorial fluid is secreted less abundantly, perhaps less elabo-
 rately ; or, in the language  of Dr. Cullen, is in a state of collapse ;
 a general  languor  and inertness prevail over every part  of the 
GE. III.-SP. II.]      SANGUINEOUS  FUNCTION.
95
system, and most of the  functions are performed feebly and labori-
ously.  And hence, if debility be  the  first stage of the proximate
cause of  fever, this part of the  cause  is continually present.  But
this is  not all;  the calorific rays of the sun act more powerfully
upon some organs  than upon others:  and most of all upon the liver.
The liver is, hence, in  a  state of perpetual irritation : an unusual
proportion of bile is  secerned, a part  of which is very  generally
resorbed and carried into the circulation ; and, in tropical climates,
so large a part  as to form one of the causes of  that tawny hue by
which the skin  is there  characterised.   And as the greater portion
of the surplus  often  passes off by the bowels,  we see  an obvious
foundation laid  for that variety of diarrhoea which  we have already
described under the epithet of bilious.   The liver, moreover, be-
comes weakened and torpid in proportion to its degree of excite-
ment; and, hence, more disposed to congestion;  and t^ere conges-
lion or any other obstruction takes place in a large organ, there is
instantly a disturbance in the balance of the circulating fluid ; and
a disturbance which, in so irritable a state of the general system as
we are now contemplating, can rarely  exist  without fever or a ten-
dency to fever.
   All this mischief is  apt to occur in autumns of temperate climates,
that are peculiarly dry  and uniform in  the range of the thermome-
ter.  But it often happens that,  even in the most temperate and
healthy climates, like our own, the autumnal months are chequered
with sudden vicissitudes of heat and cold : and the  pools and rivers
are suddenly inundated with equinoxial rains, overflew their banks,
and cover a wide  surface of land with  stagnant water.   And  the
animal frame has,  hence, to contend against  the dangers of invisible
damps, and abrupt changes of temperature,  as well as against solar
excitement:  all which  become occasional causes of fever, operat-
ing upon a state of body already predisposed to its influence.
   And, hence, even without the existence of febrile marsh-miasm,
we see sufficient causes for a more frequent appearance of fever in
the autumn than in any  other season of the year.  But in many dis-
tricts, perhaps  even in  some sporadic cases, we have reason to be-
lieve that marsh-miasm does co-operate, and itself form the remote
cause ; and more especially where such cases are frequent, the  resi-
dence a low-land,  and the season hot and rainy.
   There is still, however, a difficulty in determining why the  type
of any fever hereby produced should be remittent, rather than in-
termittent or continued; and why its declinations should imitate one
form of intermittents rather than another. Pathology habits  myste-
ries as well as  every  other branch of science ; and  let th^nan who
would accuse us of ignorance, because  we are incapable of explain-
ing these secrets  of  nature, first  tell  us, to  adopt the language of
Sydenham, " why a horse reaches his full  growth at seven years
old, and a man  at twenty one ? or, why some plants  flower in May
and others  in  June ?  If," continues  he, " the most learned men
are'not ashamed to make  an open avowal of their ignorance upon 
96
H.EMATICA.
[CL. III.-OR. I.
these points, I cannot acknowledge myself blamable if I modestly
forbear reasoning upon a subject quite as difficult and perhaps alto-
gether inexplicable.   At the same time I am persuaded, that the
progress of nature is as certain and regular in these cases as ini any
others, and that the quartan  and tertian intermittents are as subject
to the natural laws,  and as much governed by them,  as any other
occurrences whatever."                                        .
  The  autumnal remittent  commences with lassitude, a  general
soreness over the body, yawning, inquietude,  and most  of the other
concomitants of a febrile incursion.  As some of the larger organs
have  been  more affected by the influence of the season than the
rest, we find them giving way  in proportion.   Hence,  the head is
sometimes  severely  tried with pain or heaviness ; the bowels are
overloaded with bile, or the stomach is exquisitely irritable, and
rejects whajpver is introduced into it.  Generally speaking, the sto-
mach, from this symptom, suffers more than any other  organ ; and,
along with  the sickness, we  have often a very troublesome and de-
bilitating looseness which resists every attempt  to check its course.
Sometimes, however, the bowels are costive from torpor,  and the
stomach is  but little affected.
  The  violence of the  symptoms are commonly in proportion to
the violence  of the incursion; but not the duration of  the disease  :
for I have often seen a fever that commenced mildly and insidious-
ly, hold  on for upwards  of three weeks, whilst  another, that com-
menced  with great  severity and threatened the  utmost danger, has
softened its aspect in a week, and entirely quitted the  patient in a
fortnight.  The exacerbation ordinarily takes  place  at noon, or
early in the afternoon, and consists in an increase of heat and pulsa-
tion,  for there is rarely any preceding  chill,  and as rarely any
salutary moisture when the heat diminishes.   The early part of the
night is, hence, peculiarly restless, and no part of it tranquil: the
patient doses perhaps for a few minutes, but without being sensible
of sleep, and talks incoherently while  dosing;  the images before
him being  partly  furnished from dreaming and partly from delirium.
And even during  these snatches of unquiet slumber, he is perpetu-
ally turning  from side to side  in quest of ease, which no  position
affords him.  Every symptom is obstinate ; laudanum rarely produ-
ces sleep,  and no sudorific  perspiration:  the coolest and  most re-
freshing drink is rejected from the stomach ;  and if looseness teaze
the bowels, it is retained, as already observed, with great difficulty.
It is hence of little  importance what  nourishment is  offered, and
every preparation  seems almost equally  to  fail in supporting the
strength^!" the system.   In effect, the debility increases with every
fresh exacerbation;  and if no favourable change take  place before
the fourteenth or fifteenth, day  there  will  always be reason for
 alarm.
   In  the case of a young  lady in  her seventeenth year, whom  I
 lately attended,  the  attack was slight, and no  serious evil  was at
 first apprehended.  The pulse was about ninety in a   minute, and 
GE. III.-SP. I!.]        SANGUINEOUS FUNCTION.
97
 rather small; the bowels were relaxed, the motions bilious, and the
 stomach suffered  from nausea.   A gentle emetic seemed to afford
 some relief to the  stomach, and a dose of rhubarb and calomel to
 the bowels; but  the  fever continued  with a  daily and increasing
 exacerbation,  for the most part at mid-day or soon  after.   The
 stomach again became irritable and sick, and the sickness was again
 connected with a diarrhoea, but the stools was colourless and wafry,
 and nothing was rejected from the stomach but the diluent food that
 was  swallowed.  The skin was now very  hot and dry, the pulse
 from a  hundred to  a hundred and twenty strokes  in a minute,  the
 nights were passed in perpetual jactitation, or in short and talkative
 dosings.  Opium,  rhubarb, neutral  salts,  diaphoretics,  and  mild
 astringents, in almost every form and combination, were tried  with
 very doubtful advantage, and  the first with evident mischief.  Ano-
 dyne injections were  of as little avail; but sponging the limbs  with
 cold water, or brandy and  water, which  was employed as well dur-
 ing the remissive as the aggravated symptoms, diminished the  pun-
 gent heat, and for a  time afforded some refreshment.   Still  the
 fever continued its career; the stomach retained nourishment  with
 difficulty, the bowels  were daily teazed  with six or  seven watry
 evacuations; the pulse was quicker  and weaker, and the nights
 without rest.  The heart at length  became oppressed with a sense
 of fulness rather than of throbbing; the lips were considerably swol-
 len,  ragged and black ; a hemorrhage occasionally  issued  from the
 nostrils and the fauces;  and the general debility was  greatly  aug-
 mented.  Such was the appearance towards the eleventh day.   The
 tongue  was not much*furred,  the pulse, though small, and rarely
 under a hundred and twelve, was steady; but the heat was intense,
 and the thirst unquenchable.  The mineral acids in dilution, some-
 times singly, and  sometimes in  the combined form of aqua regia,
 with acidulated beverages, were now chiefly trusted  to, in connec-
 tion  with  farinaceous  foods, jellies, and  beef tea;  and cold water
 was permitted in  any quantity.  This plan  was continued till about
 the eighteenth day;  when every thing allowed being rejected, and
 every evacuation  accompanied  with faintness,  it  appeared to me
 that  the plan  should be changed ; that the chief cause of irritation
 was at this time debility;  and that a more stimulant  treatment should
 immediately be commenced.   My colleagues, .for  whom I have a
 high respect,  acceded with reluctance,  as conceiving that  we
 should only exasperate the febrile symptoms ; and that if the stomach
 could not  retain tasteless  things, it would instantly reject wine or
 convert it into an acid.  The attempt,  however, was made ; sound
 old Madeira was  administered by tea-spoonfuls,  and shortly after-
 wards a small  portion of chicken-jelly.  Both  remained  on  the
 stomach;  but the diarrhoea continued;  and  for this, as modern pre-
 parations  had proved of little use, I recommended a scruple of the
confectio Damocratis in half an ounce of cinnamon water after every
loose motion.  The diarrhoea  ceased as by a charm;  the ensuing
 exacerbation was less marked, the night was passed more tranquilly,
  vol. ir.                 13 
98                     H.EMATICA.              [CL.IH.-0R<*'

and columbo,  in small doses of the  powder, was commenced the
next morning, and persevered in.   The change of treatment, being
thus found  to succeed, was  adhered  to, and  the patient slowiy
effectually  recovered.                              ,  .   .     T>..t
  It is not often that the  autumnal remittent is thf °bst.1Dat%  *Hl
whether there be  sickness or not, an emetic should be adimnistereo,
as one of the best  means of determining towards  the skm.  Ana
singular as the advice may appear, it is rather to be recommenrted
where there is little  or no sickness  than where the sickness is in-
cessant ;  for in this last case the stomach is  often so  extremely ir-
ritable, that emetics only exasperate it  and add to the distress,  it
will also be  useful to evacuate the bowels on all occasions,  though
the emetic alone will  frequently be sufficient for this purpose :  and
hence Stoll  allows of nothing beyond ; for purging,  say* he, aug-
ments the fever, while an emetic strangles it as at a blow.*
  The use of the  lancet must depend upon the circumstances of the
particular case.   Where the onset is  violent, and particularly where
the patient is plethoric or of a vigorous habit, it should be employ-
ed instantly and freely; for, without it, from  the  urgency of the
symptoms,  there  can be little doubt that some large organ or other
will soon become  locally affected with effusion or congestion, which
is always to be avoided as one of  the worst symptoms that  can oc-
cur.  And if we have  reason to  believe  that such  local affection
exists  at the time of the attack, and more especially that it be the
cause of it, copious depletion will be still  more necessary ; for in
this case we have not only to contend with the fever, but to guard
against phlogosis  or inflammation in  the infarcted organ.
   But except in such cases  there is  no call  for the lancet,  and we
may concede  to  Stoll that  its use is injurious.  Copious diluents,
and small doses of antimonial powder in effervescing neutral draughts,
will ordinarily take off the  burning  heat of the skin by exciting a
breathing moisture; and if this can be maintained through the  day,
the ensuing exacerbation will probably be mitigated in its violence.
If not, eight or ten drops of the tincture of digitalis should be added
to the antimonial draught, and all tendency to sickness be restrain-
ed by a few drops of laudanum:  keeping the bowels in  the mean
time  open with some gentle laxative, as rhubarb, and the sulphate
or supersulphate of potash  in combination.  Blisters are never of
service except when topically called for, or as stimulants in  the last
stage of debility.    If the diaphoretic plan fail of effect, and the  heat
be pungent and augmentive, acids, vegetable, mineral, or both, will
 ordinarily constitute the best sedatives and refrigerants: and where
 the debility is extreme,  the stimulant  plan should be had recourse
 to which is laid down in the preceding case.
   One of the  severest and most fatal forms under  which the malig-
 nant remittent shows itself,  is that of the yellow fever, constituting
 the second variety of the present species: so denominated from the
* Rat. Med. Part. i. p. 227. 
GE. III.-SP. II.]
SANGUINEOUS FUNCTION.
99
lemon or orange hue which is thrown over the entire surface of the
body, almost from the first attack of the disease, and' which gives it
a distinctive feature.   The heat is here also intense, the thirst ex-
treme, and the vomiting strikingly obstinate; but not, as in the pre-
ceding species, consisting of a colourless material, or  the food that
has been swallowed, but of a yellowish matter at the beginning and
through the height of the  fever, and of a chocolate-coloured col-
luvies towards its close.
  The common remote cause of this fever is unquestionably marsh-
miasm : and hence it holds a  stationary abode in  the  swampy soils
and morasses of the intertropical regions,  exposed to  a high solar
heat, and  perpetually exhaling a decomposition of animal and vege-
table materials; and is found occasionally in all climates that make
an approach to the same character: where, in the language of the
poet,

               The rivers die into offensive pools,
               And, charged with putrid verdure, breathe  a gross
               And mortal nuisance into all the air.

   And,  as almost every territory in which it has committed its rava-
ges has given it a new  name, it is as gorgeously arrayed with titles
as the mightiest monarch of the east.  From the depredations it has
committed in  the West Indies and on the American coast, it has been
called the St. Domingo, Barbadoes,  Jamaica, and American fever:
and, from its  fatal visitations  on the Guinea coast and  its adjoining
islands, the  Bulam fever.   In British India  it is distinguished by the
name of the jungle-fever,  and still further to the east by that of mal
de Siam,  Nearer home, in the lowlands of Hungary, and along the
South of Spain, it is called the Hungarian  or the  Andalusian pesti-
lence.  From its rapid attack  on ships' crews that  are fresh to its
influence, the French denominate it jfiivre matellotte, as the Spanish
and Portuguese call it vomito  prieto, or black vomit, from  the slaty
or purplish and  granular  saburra thrown up  from the stomach in
the last stage  of the disease ; while,  as its ordinary source is marsh-
lands, it has frequently been named paludal fever.  Its more com-
mon name, however, in the present  day, and for the reason already
assigned, is yellow fever: and, when the attack upon new-comers is
slight, seasoning.
   From its showing itself in so many parts of the world, and under
circumstances so widely different, it is not to be wondered at that it
should often be accompanied with a  considerable diversity  of symp-
toms ; and consequently that the paludal fever of one quarter should
be regarded by many writers of considerable  authority as essential-
ly different  from that of another.  But an attentive perusal of the
origin and laws of febrile  miasm,  as I have endeavoured to explain
them, when treating of the remote cause of fever,* will, I trust, be
sufficient  to account for  all such local distinctions; and, if not to
* Vol. ii. p. 55. * 3. 
100                   HjEMATICA.               [cl. iil-or. I.

prove, at least to render it highly probable that they depend " part-
ly upon the state of the body at the time of attack, but chiefly upon
some  modification  in the powers  or qualities .of the febrile musm
itself, by the varying proportions of the co-operative agents of mois-
ture,  heat, stagnant  air, and  other auxiliaries which have not  yet
been  detected, in  their relation  to  each other in different places
and seasons."
  How far the yellow fever is capable of origination from any other
cause than febrile  miasm from marshy lands, we  cannot at present
determine.  When, however, it has once firmly established itself
and raged with severitj, it is now very generally admitted that the
effluvium  from the body of the affected  " is loaded with miasm of
the same kind, completely elaborated as it passes off,"-—and'that the
disorder is from this time  capable of communicating itself by con-
tagion.  And,  from the statement already given,*  it appears far
more probable that the fever at Cadiz in 1800, and that at Malaga
in 1803, had their origin in contagion, or, in other words, in febrile
miasm produced by a decomposition of the effluvium from the hu-
man body, than from the same miasm issuing from a decomposition
of marsh-lands.  And on this  account I have  rather preferred the
trivial name of yellow to that of paludal fever, which is too limited
to express its  source in every instance.
   From the different impressions  produced on febrile miasm under
these diversities of origin  and adjuncts,  we  find, independently of
other discrepancies, that the  fever it -excites sometimes assumes a
caumatic or inflammatory cast, sometimes a typhous,  and  sometimes
a synochous, or, in other words, begins with the first  and runs rapid-
ly into the second  or third.  Generally speaking, the variety before
us evinces the last of these characters, as does also the variety we
have just treated of: the two varieties  that yet remain will afford
examples of a typhous and inflammatory bearing.
   Its ordinary progress amongst those who are fresh to the tainted
atmosphere is thus accurately described by Dr. Moseley, who, from
its resemblance to the  causus of Hippocrates, denominates i't endemi-
al causus.  " When a  new-comer is seized with a  sudden  loss of
strength,  and  a desire of changing, for rest, into every position with-
out finding it in any, those symptoms which constitute the endemial
causus may be expected.  The following day, but sometimes within
twelve hours  from the first indisposition,  the violence of the disease
will commence thus: There will  be  a faintness and generally a gid-
diness of the head, with a small degree of chilliness and horror, but
never a rigor.  Then  immediately will  succeed a high degree of
fever with great heat, and strong beating in all the arteries of the
body, particularly observable in the  carotid  and temporal arteries;
 flushings  in the face; gaspings for cool air, white tongue, but tinged
 with yellow, after the  retchings have commenced; excessive thirst,
* Vol ii. p. 53. 
GE. III.-SP. II.]      SANGUINEOUS FUNCTION.              101

redness, heaviness and burning in the eyes ;  heaviness  and darting
pains in the head, and small of the back, and often down the thighs;
pulse  quick,  generally full and strong; in some cases quick, low,
and vacillating;  *k:n hot and dry;  sometimes with  a partial and
momentary moisture; sickness of the stomach from the first, which
increases with the disease ; and, immediately after any thing is taken
to quench  the  thirst, retchings  succeed in  which bilious matter is
brought up ;  anxiety with stricture, soreness, and intense heat about
the praecordia; great restlessness ; heavy respiration ; sighing ; urine
deep-coloured, and but little in quantity.  This is the  first stage of
the fever; and may continue twenty-four, thirty-six, forty-eight, or
sixty hours, and this constitutes its inflammatory period.
   " The second stage begins with an abatement of many of the pre-
ceding symptoms, and the rise of others:  sometimes with a deceiv-
ing tranquillity, but with perturbation if the patient should fall into
a sleep : then a  yellow  tinge is observed in the eyes, neck,  and
breast; the heat subsides, and sometimes  with a chilliness; but  not
with that sort of strong  rigor which,-when it  happens, terminates
the disease by sweat, or  by copious, bilious evacuations upwards or
downwards.  The retchings are violent and turn porraceous;  the
pulse flags, but is sometimes high and sometimes soft; the skin soft
and clammy; the urine  in small quantity, and of a dark croceous
colour; the tongue in some cases is dry, harsh, and discoloured; in
others, furred and moist; there is confusion  in the head and some-
times  delirium;  with the  eyes glassy.  This stage  of the disease
sometimes continues only for a  few hours,  sometimes  for  twelve,
twenty-four, thirty-six, or forty-eight hours, but never longer.
   " In the third and last  stage of the fever, the pulse sinks and  be-
comes unequal  and intermittent,  sometimes very quick;  frequent
vomiting with great straining and  noise  in  vomiting,  and what is
brought up now is more  in quantity, and has  the appearance of the
grounds of coffee, or is of a slate colour.  Nothing can be retained
in the stomach; difficult  breathing; tongue black ; cold clammy
sweats; eyes hollow  and sunk ; yellowness  round the  mouth  and
temples, and soon after over the whole body."
   These  symptoms  become gradually more  aggravated,  accom-
panied with subsultus tendinum, black urine, deadly coldness of the
limbs; delirium, faltering speech ; hemorrhage, or oozing of blood
from  the  mouth  and nostrils, corners  of  the eyes and ears; black
bloody vomiting and stools; vibices,  hiccough,  muttering, coma,
death.
*  After the first prostration of strength, the disease runs on violent-
ly till the sensorial power is exhausted.  Through its entire course,
till the patient  is sinking, the intellect is not  particularly disturbed,
and the organs chiefly affected are the abdominal;  those which,  for
reasons already assigned*,  principally suffer in the malignant au-
tumnal remittent of our  own country ;  more especially the stomach
* Epanetus malignus, Vol. n. p. 139. 
102
HiEMATlCA.
[CL. 1II.-OR. I-
and the liver.  Hence the intense heat and anxiety about the prae-
cordia, the saffron dye of the urine, the yellow tint of the skin, ana
the vomitings first of a bilious and afterwards of a chocolate or san-
guineous colluvies.                                       ,   .
  In some cases the disease opens with great vehemence, and rusn-
es forward at once to its acme,  constituting the second stage oi ur.
Mosely.  The patient is sometimes cut off in four-and-twenty houis
and, from the violence so suddenly committed on the liver,  its pro-
per function  is instantaneouly suspended, and, instead of an exces-
sive emulgence of high-tinted bile, a chlorotic secretion takes place,
which, forced into the sanguineous system, gives a ghastly Uvidity
to the entire surface.   Shortly after which, if the patient live long
enough,  the  gorged blood-vessels of the inflamed and  gangrenous
liver itself, and sometimes also  of the spleen  or stomach, give way,
and repeated tides of dark granulated grume, like the grounds of
chocolate, are ejected by the mouth.
  Mr. Pym has very forcibly described this overwhelming onset of
the disease in the following  terms: " There is at the first attack a
peculiar shining or drunken appearance in the eyes; the head-ache
is excruciating and confined  to the  orbits and the forehead; has no
remissions;  when it terminates favourably, is rarely attended with
yellowness of the «kin, which, if it do take place, is of  a very pale
lemon colour.  It runs its course from one to five days, is  attended
with a peculiar inflammation of the stomach, which, in most cases
that prove fatal, terminates in gangrene, or in a diseased state of the
internal  or villous coat of that organ, accompanied with a vomiting
of matter resembling coffee-grounds, and  a livid or putrid appear-
ance of the countenance which it  is impossible to describe ; but
those wishing  to form an idea  of it may see its fac-simile in the
countenance  of any  person  with  a florid  complexion, during the
burning of spirit of wine and salt in a dark room, as is  practised in
the game of snap-dragon during the Christmas gambols."*
   In this state  the disease is unquestionably contagious: and as Dr.,
Cullen has laid down  contagion as  a distinctive character  of fevers
originating from  human effluvium, in contrast with those originating
from the effluvium of marshes, Mr.  Pym has endeavoured to draw  a
line of distinction between yellow fever in this state of intensity and
in its ordinary career; contending that the  former (to which he
limits the name of Bulam fever) is in every instance derived from
human effluvium, and consequently that the two must of necessity be
distinct diseases.   And to make the distinction still clearer,  he has
ventured to  assert that the  symptom  of a more  pallid or bloated
countenance, together with that of black vomit, or the discharge of
coffee-like grounds from the stomach,  is peculiar to the contagious
 fever, and is rarely if ever an attendant on that produced by marsh-
 miasm even in its most impetuous and fatal course.
   This distinction, however, is in both instances at variance with
* Observations upon the Bulam fever, &c. 8vo. 1815. 
BE. III.-SP. II.]      SANGUINEOUS FUNCTION.              103

the history of the disease as it has  occurred in most other parts of
the world, and more especially with respect to the symptom of black
vomit, which in its last stage or severer incursions, is common to it
from whatever source derived.  It  occurred more especially in the
fatal epidemic of  Antigua in 1816,  which was decidedly an off-
spring .of marsh-effluvium.  The island had for some years, observes
Dr. Musgrave,* at whose description we have already glanced slight-
ly, been peculiarly healthy:  and the  disease first showed itself in a
swampy part of it, and amidst new-comers  who were  sailors, but
from a healthy ship, and themselves in good health on first landing.
It soon spread widely, and a't length indiscriminately among all ranks
and conditions, and situations—among blacks and whites, the  newly
arrived, and the oldest settlers in town and country.
   Nothing  was better calculated than this fever to show that  al-
most  all the different kinds of fever  that occur to  us, are capable
of issuing from a common source or miasm, merely modified by con-
tingencies :  for in  Antigua they all occurred in different individuals.
The disease  sometimes commenced  as  an intermittent or remittent,
and sometimes in a continued type  ; it sometimes ceased in four or
five days, which was its usual course,  and sometimes terminated in an
intermittent.   The head was in some  cases chiefly affected ; in oth-
ers the stomach, liver, or some other organ : sometimes the patient
died without hiccough or black vomit, though he rarely recovered
where these symptoms appeared ; Dr. Musgrave recollects but one
instance.  Recovery was no exemption against a second attack.  In
new-comers the tint was of a lemon hue;  in native or assimilated
constitutions, of a deep orange.   The  state of the atmosphere at the
commencement of the disease presented nothing peculiar.
   In the midst  of the  discrepancy between these two accounts, there
is still  much that is concurrent, and quite  enough  to establish the
identity of the two diseases, if an  abundance of other  evidence to
the same purpose were not at hand.  The fever of Mr. Pym,  speci-
fically characterized by black vomit, is represented as  being pecu-
liarly dangerous and fatal;  in that  of Dr.  Musgrave, this  symptom
only occurred in the most dangerous cases of the malady.   Accord-
ing to the latter, the severest and most deadly attacks were amongst
the new-comers; the  mildest, amongst the natives or those whose
constitutions were assimilated to the climate. The yellow hue  of the
former (and I have already  endeavoured to account for this) was of
a deep orange, that of the  latter, a lemon colour.   Mr. Pym describes
three species of fever as common to warm climates, but which dif-
fer from each other in their mode of origin, and diagnostic character.
In that of least  danger, the colour of the surface, he tells us, is of" a
very deep yellow ;" in that of higher danger, it is of " a deep yellow ;"
and in the disease before  us, which is  by far the most fatal, where
there  is any yellow at all, it is of " a very pale lemon colour;" which
* Medico-Chirug. Trans. Vol. p. ix. 92. 
 104                    ILEMATICA.             [O- HI.-OR.  I-

is, in effect, the very hue ascribed to the severest cases of the Anti-
gua fever by Dr.  Musgrave, as the  " very deep yellow," or " or-
ange," is to the mildest.   So that, examined by their external livery
as well as their internal disorganization, there  can be no doubt that
the two diseases are the  same.  Mr. Pym appeals peculiarly, as  a
distinctive character of the Bulam fever, to the deadly and  chlorotic
paleness exhibited by the  countenance, in  its latest stage, or most
fatal incursion.   But" even this only shows that,  in such  case,  the
disease makes a mortal attack upon the larger viscera, and especially
the liver, from  the  first;  and  demonstrates  the proposition I have
ventured to lay down, that  in  proportion as this organ  is severely
affected is its inability to  secrete proper bile or indeed bile of any
kind: and,  consequently,  that  if the irritation only reach  a certain
point, the secernents will be stimulated to emulge a larger quantity
and of a deeper hue; a considerable portion  of  which, in  conse-
quence of such irritation extending to  the neighbouring absorbents,
will be sent back  into the  sanguiferous system,  and  produce  the
orange tinge, which, in the description of both these writers, pecu-
liarly marks the disease before us in its less fatal attacks. While, if the
febrile incursion be so violent as totally to derange the function,  and
still more the structure of the liver,  no. bile  will be secreted at all,
or if secreted, less  in quantity and consequently less diffusive in col-
our ; and hence only conveying a chlorotic or livid tinge to the face,
which at the same time exhibits  a bloated fulness from effusion or
debility of vascular action.
  Yet, after all, it is not denied by Mr. Pym, nor, so far as I know,
by any of the writers on the American or Andalusian fever, that the
yellow fever from  marsh-miasm ever evinces either of the symptoms
that are so essentially ascribed  to the bilious remittent produced by
contagion, but only that "it is  rarely,  if ever," to adopt Mr. Pym's
own words, "  attended with the  fatal symptoms  peculiar to  the
Bulam fever, viz. the black vomiting, and a peculiar bloated appear-
ance of countenance."
  There would, however, be an almost insurmountable difficulty in
reconciling these different descriptions of the same disease, in con-
sequence of Dr. Musgrave's telling  us,  very decisively, that not  a
single instance  occurred in the Antigua fever of its being  received
by contagion, were there not strong  reason for believing, as I have
already observed on another occasion,* and hence need not go over
the ground again,  that this explicit  writer suffered  himself to be
deceived upon this point;  most  probably, like Mr. Pym,  from  too
close  an attachment to the doctrine laid down by Dr. Cullen that  the
fever from marsh-miasm does not produce contagion, which is speci-
fically a result  of a fever from  human effluvium.
   It is impossible to peruse the history of bilious remittents in warm
climates  offered from all  quarters, without seeing that  it may  and
does originate from both sources ; each sometimes operating alone
* Vol. a. p. 47. 
GE. III.-SP. II.]       SANGUINEOUS FUNCTION.              105

and sometimes in conjunction with the other, as was probably the
case at Antigua, and certainly the case  in the yellow fever that
raged at Philadelphia in 1793 ; in which, says Dr. Rush, there were
for  several weeks  two sources  of infection, viz. exhalation  and
contagion.   The exhalation infected  at  the distance of three  and
four hundred yards ;  while the contagion infected only across the
streets.  The  more narrow  the streets, the more certainly  the
contagion infected.   Few escaped it in alleys.   After the twelfth of
September, the  atmosphere  of every street in the city was loaded
with  contagion; and there  were few citizens in  apparent good
health, who did not exhibit some  mark  or  other of it in their
bodies, particularly a preternatural quickness in  the pulse, " which
occurred in negroes as well as in  whites; and in  a few who had had
the disease before."
  That febrile miasm produced from human effluvium is less volatile
than that from marsh-miasm, and consequently more limited  in its
range of infection, is consistent with common observation, and a fact
I have already endeavoured to explain.  It is sufficient to observe,
on  the present  occasion, that  the disease thus issuing from  two
distinct sources was one and  the  same in its general symptoms, and
yielded to a like treatment: thus  establishing  satisfactorily, what
indeed Dr. Rush himself does not seem to have apprehended, that,
though remotely issuing from  two distinct sources, it was imme-
diately excited  by a common  miasm thus  doubly generated,  and
which was only  modified in its action  by the nature of its origin, or
by contingent powers.
  Unfortunately  the practitioners in warm climates have differed as
much in their  therapia as in their etiology :  and apparently the
cause that has produced the one has produced or greatly influenced
the other.   Mr.  Halliday alarmed at the  debility which the system
will have to encounter in the second stage of the disease, or as soon
as it  has run through  its  inflammatory career, shuddered at the
thought of the lancet; commenced with slight purgatives of sulphate
of magnesia and  manna, and immediately  afterwards had recourse lo
the bark.   The  practice of Dr.  Hillary  was something less  timid ;
for he allowed  an abstraction of from twelve to twenty ounces of
blood on the first, and even in a few cases again on the second day,
according to the patient's strength and constitution.  While Dr. Rush,
on the other hand, regarding the inflammatory impetus as the sole
cause  of danger, boldly resolved to  lay prostrate if possible  the
morbid Hercules at its birth,  by bleeding, according to the state of
the pulse, two or three times  a-day during the first two days, and by
following up the same plan, as  long as a  single germ of an inflam-
matory diathesis should continue manifest.  " 1 paid  no regard,"
says he, " to the dissolved state of the blood, when it appeared on
the first or second day of the disorder, but repeated the bleedings
afterwards, in every case,  when the pulse  continued to indicate it,.
It was common to see sizy blood succeed that which was dissolved.
The dissolved appearance of  the blood 1 supposed to be the effect of
  vol. ii.                   14 
106                     hjsmatica.             [cl. m.-oR. *<

a certain  action of the blood-vessels upon it.  The presence  of
petechia? did not deter me from repeating blood-letting where_ the
pulse retained its fulness  or tension."   And he  affirms,  that both
petechiae  and vibices  disappeared in various  cases  alter bleeding.
This plan he often pursued through the  fifth and even the seveQ"|
day, in the course of which period, from a hundred to a hundred and
twenty ounces of blood were frequently  taken away by  six or eight
applications of the lancet.                                       ,
  His purgative  plan was not less alert.  Ten grains of calomel and
fifteen of jalap,  was the force with which he opened his remedial
attack, and which he repeated every six hours, till the  alvine canal
was effectually evacuated.  This mode of treatment, he tells us,  he
was led to by accident;  and with it he  became  as successful as  he
had been unsuccessful under the tamer and more established method.
  Yet it is the  boast of those who have  pursued  this tamer, and
formerly more established method, that,  though quicker and less
striking, it has, in the  general balance of the account, proved more
salutary than the formidable plan of their  antagonists.
  There  is not, however, necessarily any opprobrium medicorum
in this discrepancy ; for it is probable that in different  situations or
under different  circumstances, both plans  have  been  equally judi-
cious and  equally successful; for we  have  seen  that the disease
under different incidents and coadjuvants has exhibited every variety
of  violence, and inclined  to almost every variety of  febrile type.
Where there is  not much impetuosity in the onset, no great derange-
ment or prognostic  of inflammatory congestion in the larger viscera,
where the remissions are  regular, and the  epidemy is pretty uniform
in  its character, large and repeated bleedings,  as  a general rule,
must prove mischievous.   They will not shorten the career of  the
disease, but they will convert the remittent into a continued fever:
and we shall in  the latter stage of its course stand woefully in need
of  that strength which we shall have  squandered away at first, if
we have  commenced  with profuse venesection.
    On the contrary, if the disease make  its  incursion  with great
impetuosity;  if the pulse be full and strong, or even if it be only
hard, and there is great tendency to inflammatory congestion in  any
 of the larger organs, as the head, the chest,  or, as is far  more
 common, the stomach, the spleen, and the liver, we cannot well be
 too bold both in bleeding and purging; and the plan laid down by
 Dr. Rush is by no means an  exaggeration of what  ought to be
 pursued.   It may be, that eight-and-forty, or even four-and-twenty
 hours are the whole  we have to work in; and unless we can, so to
 speak, stifle or lay prostrate the  sensorial power, and thus com-
 pletely break down Jhe inflammatory diathesis by debilitating  and
 relaxing the living fibre or solidum vivum, rather than by diminish-
 ing the moles movenda, the organs mostly affected will in all pro-
 bability become gangrenous in a day or  two, the oppressed blood-
 vessels will give way,  and we shall have a chlorotic  or livid skin,
 cold extremities, black vomit, and all the other apparitors of death. 
GE. 1II.-SP. II.]     SANGUINEOUS FUNCTION.               107

before the tamer plan of aperients and  diaphoretics could have
time to produce the slightest impression on the system.  Generally
speaking, it will be best to bleed in an erect position, for the sen-
sorial excitement, which is what we are chiefly to aim at, is best
cut down by syncope, which an erect position will soonest induce ;
and we may, hence, save the expense of several subsequent bleedings.
  There is no doubt that by a praxis thus active and resolute, very
vehement attacks of the yellow fever have sometimes been subdued
ih a few  days.  But let not those who have thus triumphed conceive
that by the same  process they would have as soon put to flight less
violent incursions of the same disease that have been treated in a
different  manner  ; for the  more acute the disease, the  shorter its
duration, in most instances; and hence,  had no  medical treatment
whatever been resorted  to, the fever might have run through its
course, whether fatally or happily, in  a  less period than if it had
commenced more leisurely and insidiously.   Yet it is very far from
being always that an early  return to  health is the  consequence  of
this daring practice, however judiciously it may be had recourse to,
and though it  may  have been the only means of rescuing the
patient from  death; for the double debility induced by the disease
and its remedy have often laid a foundation for dropsies and other
cachexies,  which have required years to master, and which have
sometimes never been mastered at all.
   Dr. Pinckard, in his " Notes on the  West Indies," has  given a
very interesting description  of his own sufferings  under this  disease,
and of the  remedial process to which he  had recourse.  His attack
commenced in the more common manner, slowly and insidiously, and
demanded eight or nine days to reach its acme.  His head, stomach,
and at last  his bowels, were severely affected, especially the first;
but his intellect continued sound;  and, though the symptoms were
vehement,  there  seems to have been little tendency to that violent
visceral  inflammation which in the stage of debility is so apt  to
produce  gangrene ; and consequently he  had no black vomit.  He
lost twelve or fourteen ounces of blood at the commencement of the
disease,  and  took a strong dose of calomel, which considerably
relieved  the  pain in his head and eyes, and diminished the restless-
ness ; but the thirst, heat, and dryness of the skin were still intense;
and his  weakness became extreme.  Affusions of cold  water, old
hock, opium, and bark,  were made use of in profusion, and each
seemed to afford great relief.  Yet  on the subsidence of the fever,
he represents his feebleness as most  deplorable,  and  such as  it
appeared impossible  to  recover from.   Here a mere use  of the
lancet could  have been of no avail, and, had not the author most
judiciously forbade its further  employment, in  all probability he
would never  have been the  historian of his own case.*
   Mr. Pym speaks with a very just discrimination upon this subject,
in observing, that while the Bulam fever, or the disease in  its most
*' Vol. in. Letter xii. p. 134. 
108
H/EMATICA.
[CL. IH.-OR. 1.
violent attack, is  relieved by free venesection, the  yellow fever
more properly so called from the brighter  hue on the surface, or,
in other words, that which is slighter in its incursion,  will not often
endure the lancet.  Dr. Musgrave's statement seems to oppose this
assertion, for he  distinctly tells us that " blood-letting in both forms
is our sheet-anchor;  the only pillar on which we can securely rest
any hope of extensive success "   The Antigua fever seems to have
exhibited great  severity in most instances, and hence called tor a
courageous course of practice with  perhaps few exceptions.  Yet
the following paragraph proves that it did admit of exceptions, and
softens  down almost  to unanimity a  clash of opinion and mode of
cure which after all is more ostensible than  real; " we have repeat-
edly," says  he,  " with success  taken  upwards  of forty ounces of
blood at one bleeding.  With  equal success we  have in several
cases renewed the bleeding up  to the third, and even  the fourth
time $  but generally speaking those which  require such  reiterated
evacuation, evince an obstinacy not likely to admit of a favourable
RESULT UNDER ANY MODE OF TREATMENT.  It MIST ALSO BE REMEMBERED
THAT EVl.RY ONE WHO APPLIES FOR ASSISTANCE IS NOT ALIKE ABLE TO BEAR
this liberal depletion."  It only needs to be  observed further, that
the bowels were emptied as they ought to  be by calomel or jalap,
or some other active purgative ;  the  head  was  shaven, and cold
ablution preferred ordinarily to cold affusion,  because of the fatigue
endured under the latter.  Bark  was then  instantly given,  and,
where the stomach would bear it, in the powder.   Mercury,  with a
view  of exciting salivation, was seldom tried, and not relied upon.
In effect, in the milder cases  it is not wanted for this purpose, and,
in the more  urgent, there is no time  for its  use.           r
   There is another variety of malignant remittent which has been
known to medical practitioners from the time  of the Greeks, though
less frequent than the  yellow fever, and which, by  Hippocrates, has
been denominated causus ; as it has by later writers, who have only
translated the Greek term, been  called " febris ardens, ardent  or
burning remittent."   In Hippocrates it  is briefly described as a
fever, characterized by extreme heat, violent thirst,  a  rough and
black  tongue, complexion inclined to yellowish, saliva bilious.
There is commonly an acute aching in the  head, nausea, great anx-
iety of the praecordia, with frequently a gnawing  pain at the sto-
mach.  The bowels are unusually  costive,  particularly at the com-
mencement of the disease.  The tongue, mouth,  nostrils, and, in-
deed,  the  whole  surface  of the body  is parched  and  fiery-hot,
whence, indeed,  the Greek name for  the  disease ;  the pulse is full
and strong:  the voice hoarse ; the breathing  short and quick, with
sometimes a slight cough, and occasionally  delirium :  Dr. Moseley
conceived it to.be the  yellow  fever we  have just described ; to
which, indeed, it makes, a near approach, though it has several dis-
tinctive symptoms.  The burning heat is more intense,  the thirst
more intolerable ;  while the stomach is less irritable  ; and will bear
vomiting with advantage: there is no black vomit  at  any time : 
GE. III.-SP. II.]      SANGUINEOUS  FUNCTION.
109
and, in the second stage, the chilliness which, in the yellow fever,
is  merely  accompanied  with  horripilation,  and  is a  mischievous
symptom, in the causus is accompanied with  a smart  rigor which
terminates  in a copious and salutary sweat.  The attack moreover
seldom lasts more than four days:  and is  usually terminated  by a
critical diaphoresis, vomiting,  diarrhoea or nasal hemorrhage: and,
if these do not carry it off, it generally proves fatal.
  It chiefly attacks the young and the vigorous, who  bear  the  at-
tack better than old persons.   The causes to which it  was former-
ly ascribed, are, long exposure to the heat of the sun,  great fatigue
fron^undue exercise or labour, or too heating a diet.   It has of late,
however, been supposed, and  with much  plausibility,  from  its fre-
quent  occurrence towards the autumnal equinox, and especially
from its resemblance  to the yellow fever,  that, like the latter, its or-
dinary remote cause is the miasm of  swamps and marshes.  And, if
so,  it affords us a proof that, under certain modifications, febriie  mi-
asm issuing from this  source, may, as I have already suggested, pro-
duce a caumatic or inflammatory, as well as asynochous or typhous
tendency, in constitutions predisposed to this character  of fever :  for
the causus is,  in fact, whatever be its cause, a vehement inflamma-
tory remittent;  and hence its treatment  is not difficult.  Bleeding
and purging are here unquestionable.  And, when these had been
carried to  a sufficient extent,  Hippocrates added the use of cold  ap-
plications in every way; the  coldest possible drinks; the  coldest
possible  clysters, and ablution with cold water  applied to every
part of the body.*  Under proper regulations there is  no doubt of
the advantage of such a  treatment,  and the medical records  of  the
continent, as well as of our own country, throng with cases in which
it has been found serviceable.   Marquet recommends the application
of cold air as  well as of cold water; and gives an instance of a ra-
pid cure in one who  in a state of delirium exposed himself naked
to the  cold of the  atmosphere out of doors.t  And on this  account
Schaffer advises that  the patient, in any acute fever  accompanied
with dry burning heat, should be carried forth from his chamber, on
a mattrass, and thoroughly ventilated abroad.J
  In the preceding varieties,  the malignant remittent  has shown a
tendency to an inflammatory or a synochous  career.   Under  parti-
cular circumstances,  however, it evinces a like inclination to a
deep nervous  depression, sensorial debility, or a typhous  character
from the first.  And this, whether the febrile miasm originate from
a decomposition of marsh, or of human effluvium ;  for the  records
of medicine furnish us with innumerable  instances of  both.   In  the
two cases, however, there are a few  slight variations  in  the range
and mode of its action, the laws of which  1 have already endeavour-
ed  to lay down as far as  we are acquainted with  them.§  This mo~
* Tlty Ilaiw p. 518, 1. 48. 51. p. 419. 1. 37.
t Observations sur la Guerison de plusieurs Maladies.
t Versuche. i. p. ltS4.             $ Vol. II. p. 53. 
110                    HJEMATICA.             [CI" 11I•"-,
dification of the disease, therefore, is best distinguished by the name
Of ASTHENIC REMITTENT.
  The epidemics of this kind that are accompanied with most mor-
tality are those which arise from a decomposition of human effluvi-
um in the midst of filth, poverty, or famine, great heat and  moist-
ure, crowded multitudes, and a  stagnant atmosphere : for here  we
have almost all the  auxiliaries  of febrile  miasm operating  for its
production.   The remittent epidemics  of Cadiz  and Malaga seem
chiefly to have been of this kind : and they are the common pesti-
lences of dis-spirited armies, maintaining their ground with difficul-
ty in the midst of great carnage, surrounded by  the  dead and  the
dying, reduced to short provisions, and worn out by the  fatigues of
the campaign.  The writings of Sir John Pringle are full of exam-
ples of this kind ; and Professor De Haen has  given a striking de-
scription of the same in his account of the contagious epidemy that
committed such tremendous havoc throughout the Prussian army, at
Breslaw and its vicinity, in the  middle of the last century, constitu-
ting the disease to  which  M. de Sauvages has given the name of
tritaeophya Vratislaviensis.  It  was peculiarly distinguished by ir-
regular action, great debility, and overwhelming dejection of mind.
The  lipyria,  or  coldness  of the  surface, with  which the disease
opened, rarely yielded to any general re-action, for the extremities
seldom became warm, and were often rigid and convulsive; at  the
same time that the  interior parts burned like a fire; the head  and
stomach suffered with acute pain ; there  was great anxiety about
the praecordia ; and so exquisite a soreness over the  entire surface
that the patient had the greatest dread of being exposed to the con-
tact of the  external air, a  mere change  of the  temperature being
intolerable.  De  Haen himself at length became a prey to the in-
fection, and his attack commenced as thus far stated.   On the fourth
day, he tells  us, all his symptoms were worse, his feet quite chilled,
but his hands red, and agitated  with convulsive motions ; he had oc-
casional vomitings, and was terrified by  the  image of impending
death.  On the eighth day the pulse was convulsive, and  he  was
continually crying out from his pains.  On the ninth, delirium, and
a rejection of grumous blood from the stomach.  On the eleventh,
perspiration  and a  tranquil pulse, but the voice  was broken, the
speech was interrupted, and the teeth grated.   On the twelfth, the
jaw was convulsed, there  was a sardonic  laugh  and deafness.  On
the fourteenth, an icy coldness covered the whole body, accompanied
 with a cold sweat,  but a frequent use of ablutions afforded  relief.
 On the eighteenth, he had a vivid  delirium,  but  fainted on being
 taken out of bed; which was succeeded by hunger, copious sweats,
 and profound sleep,  with  an intolerance of  noise.   At this time,
 every thing  appeared new and extraordinary ; a feeling described
 by many sufferers as soon as the violence of the disease begins  to
 abate, and which Dr. Pinckard has very strikingly noticed in  his
 own case.   The  symptoms varied  considerably from this  period,
 and he had  still  many danger* to contend with.   He recovered. 
GE. III.-SP. II.]
SANGUINEOUS FUNCTION.
Ill
however, though very slowly, and with numerous draw-backs; for
on the thirty-sixth day he had a cholera, and on the  forty-eighth
his  skin  scaled off, and he lost his nails.
  Towards the close  of  the  disease, the skin was covered with a
scabid or ichorous eruption, rather than petechia?;  evidently from
debility of the capillaries: a fact that  has often  occurred even in
the slighter attacks of this variety of remittent in our own country,
when it has occasionally broken out, as in 1765,  among the troops
stationed in the  vicinity of Portsmouth, and is particularly noticed
by Dr. Lind.  In this last case it was often suspected to be the itch,
to which it had  a very near resemblance : and it  is highly probable
that in many instances it was so, and that the  acarus scabiei found,
in the sores, a convenient nidus for the deposit of its eggs.
   There are situations, however, in which the febrile miasm  pro-
ducing this low  variety of remittent is generated by  a decomposi-
tion of the stagnant matter of humid marsh-lands  ; such chiefly are
the regions about Cape Coast, in Africa, especially when visited by
the  foul and smouldering harmattan, and about Gombrow,  or as
Sir John Chardin calls it, Bander-Abassi, on the Gulf of Persia :* in
which last place the mortality is so severe between the months  of
April and September  that the deaths  are ordinarily  calculated  at
nine out of ten  of the  inhabitants: and  this notwithstanding that
most of them retire during such period  towards  the mountains, and
all mercantile concerns are relinquished; so that, says the Cheva-
lier, " la moisson est fermee comme un parle."  The diseased are
commonly removed higher up the country as  soon as they sicken;
but,  whether removed or not, they usually die in four or five days.
   It is possible  that in both these places the danger of the disease
may be  augmented by the dense and stinking  vapour that is perpe-
tually blowing upon them during the pestilential  season, the " puan-
tes vapeurs de la mer,"  as Sir John expresses himself, " qui faient
bondir le coeur la premiere fois qu'on le sent."   These on the  Afri-
 can coast are impregnated from the impenetrable mangrove swamps
 of the interior of" Guinea, and,  on the Persian, from the saline and
 sulphurous exhalations of the  several adjoining  islands which the
 winds of the season pass over in their periodical  sweep: and the
 copious disengagement of hydrogene,  whose  presence the intoler-
 able stench seems to indicate, will account in no small degree for
 the deficiency of living power,  which  so  peculiarly distinguishes
 the malignant remittent in these quarters,  in the latter region, in-
 deed, some such debilitating influence seems to  operate habitually :
 for the  ingenious author thus quoted adds, that " the  nations carry
 in their complexion and constitution the  proofs  of their  malignant
 atmosphere, being yellow and ghastly from the  age of  twenty-one,
 and decrepid at thirty."
    Bleeding in this  disease can never form a part of the general
 practice, how necessary soever it may be in particular cases, where
* Voyage du Chevalier Chardin, &c. Tom. ix. p. 511—518. 
112
H^MATICA.
[CL. Ilt.-OR. I.
atonic congestion  may  oppress the head or the heart.  The first
requisite is pure air when it can be procured: the bowels must be
•pened and kept open by active purgatives, since, from the general
disturbance of the functionary balance,  there  is  violent action  in
the abdominal viscera, while the vessels on the surface are entirely
torpid.  To restore this balance  should be our next effort:  and tor
such purpose nothing bids fairer, or has in  fact been found  more
successful, than the use of warm diaphoretics with  opium.  Oold
water as a beverage, or in the form of injection, has also proved  a
highly refreshing tonic; frequent potations of old hock still  more
so; and the bark may be commenced with advantage as soon as the
stomach can retain it in large doses, for here small proportions are
of no avail.   Ablution with cold  water was  also tried very  gene-
rally during the  malignant epidemic at Breslaw, and wi(h very
great advantage.*
                       SPECIES  III.

                EPANETUS HECTICA.

                       f^ecttc iPcber.

PULSE WEAK : STAGES OF  CHILLINESS, HEAT  AND SWEAT VARIOUSLY IN-
  TERMIXED, AND SOMETIMES  SINGLE; THE COLD  STAGE EXHAUSTING J
  THE EXACERBATION CHIEFLY IN THE EVENING.

The symptoms of this species, except in its sweating stages, are far
less violent, and consequently its duration is far longer  than that of
either of the preceding.  Nothing, however, can more fully prove
its complexity and irregularity, than the different characters given
of it, and the  different places  allotted to  it, by different authors.
Sauvages and  Sagar  introduce it into the  list of continued fevers.
Linn^us, Crichton, and Parr, into the present division, or that of remit-
ting and exacerbating fevers  : Boerhaave regards it as of a mixed na-
ture, a continued intermittent.  " Febris hectica," says he, " est re-
ferenda ad  febres continuatas intermittentes.1'   Vogel and  Cullen
degrade it  into a mere symptomatic affection.   " As I have never,"
says the latter, " observed a fever of this kind  except  when symp-
tomatic, I could not  consent to  admit it into the list of  idiopathic
fevers,  which  alone  ought to be enumerated."
  Those who have adopted  Dr. Cullen:s opinion, have usually con-
templated  it  as a mere  effect of  absorbed pus.   Dr.  Heberden
  * Epidemia verna quae Wratislaviam, anno 1737, affiixit. Vide Act. Nat. Cu-
rios. Tom. x. 
GE. III.—SP.  HI.]        SANGUINEOUS FUNCTION.             113

seems to think it dependent upon a local cause, but that  irritability
in any diseased organ, which cannot be brought into a healthy state,
will excite it as eflectually as pus introduced into the system.
  Galen, on the contrary, Mr. John Hunter, and Dr.  Willan, con-
tend, that hectic may be, and often is, a strictly idiopathic affection.
The second of these  valuable writers regards  hectic fever  as  of
two sorts symptomatic and idiopathic*   The first he ascribes
entirely  to  local irritability, and opposes the  idea that it is  ever
produced by absorbed pus.   His  argument is, that if absorbed pus
be  capable of producing it  in one instance, it  ought in every in-
stance : but  this we know is not  the case ; for we have had  large
buboes and  even  empyemas removed by absorption suddenly, and
yet no hectic has taken place.  He does not think that more  pus is
absorbed during the  existence of  hectic fever  than when no  such
fever is  present: but, admitting that this should be the  case, he
would rather ascribe the increased absorption to the hectic consti-
tution, operating upon the abscess or sore, than to the abscess or sore
operating upon  the constitution; in which case the hectic diathesis
is the cause,  and the  increased absorption is  only the  effect.  So
that even here, he regards the hectic as a primary or constitutional
 fl]Cp£)60
   As a symptomatic  affection, however, he  refers it to a general
 irritability  of the constitution,  produced by  sympathy, in conse-
 quence of " some  incurable local disease of a  vital part, or of a
 common part when  of some magnitude ;"  and which becomes in-
 curable  from two causes; firstly, because, though the local irritation
is small,  the constitution is bad, and does not dispose the parts to a
 healing  state :  and secondly, because,  though  the  constitution  is
 o-ood, the local  irritation is so considerable that it cannot muster up
 a sufficiency of remedial  energy to subdue it; and  hence,  while
 sympathizing in the  irritable action, falls a prey to its own efforts.
   Yet, says he, it is possible for hectic fever to be an original dis-
 ease of the constitution;  for the constitution may fall into the same
 mode of action, without any local cause whatever, at least that we
 know of.   And in this  manner he  accounts tor its existence as an
 idiopathic  affection.  And,  in effect, nothing is more common than
 for hectic  fever to exist in patients in  which we can  trace no local
 cause whatever : and in all such cases we  must either indulge in a
 gratuitous hypothesis, and throw our suspicions  at random upon the
 lungs, or the liver, or the kidneys, or thtfheart, or the mesenteric
 glands,  or whatever  other organ a few casual symptoms  may  suggest
 to the fancy; or we  must at least act upon the principle of its being
 an idiopathic affection,  even though we should  refuse,  in terms,  to
 admit that it is so.                                     .
    " I willingly subscribe,"  says Dr. Perceval of Dublin, in his ma-
 nuscript comment upon the authors Nosology,  "  to idiopathic hcc-

                  * On Blood, Part 11. Chap. ix. Sect. i.
VOL. II.
15 
1 14                     HtfMATlCA.            [CU HI.-OR- I.
tic; and have known it to last three months without any pulmonary
affection, and then to break out in the lungs."
   There seems, indeed, great reason for admitting with Dr Stoll, a
habitus phthisicorum* a hectic diathesis or temperament; the features
of which are for the most part strongly marked, and are to be found
in a fair skin, blue eyes,  yellow hair, lax fibre, and sanguine dispo-
sition.   And, wherever this exists, it is probable that  most of the
causes  of other fevers,  operating upon  it,  will  produce a hectic.
And  we can hence readily account  for  the  examples  brought by
different authors of its being excited by  diseased actions or affec-
tions of the  heart,  stomach, mesentery, liver,  pancreas,  lungs, or
brain ;  by a suppression  of various  exanthems  or other eruptions,
or of various habitual discharges natural  or  morbid;  by other fe-
vers ; by chronic inflammations or abscesses.   It is well known to
be a common sequel to  the measles, occasionally so to the small-
pox, and in a few instances to rosalia or scarlet fever.   It may hence
be a result of dyspepsy; and one case is said to have been produced
by eating  bacon, which  remained undigested in  the stomach  for a
term of eighteen months, when it  was disgorged by sickness, and
the hectic symptoms  disappeared.t  And it is hence possible  that
hectic fever may occasionally spring  like other remittents, from fe-
brile miasm.
   The character of the  disease is well given by  Mr. John Hunter
in the following words:   " Hectic may be said to be a slow mode of
dissolution; the general symptoms are those of a low  or slow fever,
attended with weakness, but more with the action of weakness than
real weakness; for, upon the removal of the hectic cause, the action of
strength is immediately produced, as  well as every natural function,
however much  it was decreased before.  The particular symptoms
are debility ; a small, quick, and sharp pulse ;  the blood forsaking
the skin ;  loss of appetite ; often rejection of all aliment by the sto-
mach ; wasting; a  great  readiness to  be thrown into sweats; sweat-
ing spontaneously when in bed;  frequently a constitutional purging."
—To which he adds, " the water  clear."   There is, in reality,
much difference of opinion upon this last  point.  Dr. Heberden has
observed that the same irregularity which accompanies most other
symptoms of the disease  attends this  also; that the urine is equally
clear  or turbid in  the exacerbations and  the  intervals ; sometimes
clear in the first and turbid in the second  ; and sometimes  turbid in
the first and clear in the Second : while Dr. Duncan,  from long and
assiduous attention, asserts, that the urine is peculiarly distinguished
by a natural furfuraceous separation.   Such is the character it has
usually  exhibited in my  own practice : though where authorities
thus clash,  it is not a symptom to be  depended  upon as a pathog-
nomic.
   From the frequent approaches which the hectic makes towards a

              * Prselect. p. 19.
              t Arnold. Diss, de Hectica  stomachia, 1743. 
GE. III.—SP. rll.]    SANGUINEOUS FUNCTION.                115

perfect apyrexy, it is sometimes apt to be confounded with an in-
termittent;  but  there is rarely any remission in which the pulse is
not at least ten strokes in a minute quicker than it ought to be; and
by this it is sufficiently  distinguishable, as it is also by the greater
irregularity of its different stages, and indeed of all its symptoms.
  It is owing to  this last feature that, sometimes,  the exacerbation
commences with a chilly fit, and sometimes without; and that, when
there is a chilly  fit, sometimes it  is immediately succeeded by heat,
but sometimes by  perspiration,  without any intervening hot fit;
while occasionally the cold fit only leads to heat, or even terminates
singly without either heat or perspiration.  Hence the exacerba-
tions must vary in duration : but even where every stage is present
and succeeds in  regular order, the duration of the entire exacerba-
tion is almost equally  uncertain, insomuch that it is seldom  that
three  exacerbations of equal length recur in succession.   The re-
missions  will sometimes extend  to ten or twelve  days, without a
single intervening pyrectic symptom: and sometimes the cold or the
hot fit, or the sweating, will be renewed several limes in the same
day.  Yet, let the perspiration appear whenever it may, the patient
is never relieved by it;  but is as anxious  and restless during its
continuance as in the heat or chill.
   Dr. Heberden* tells us, that he has sometimes seen a hectic at-
tack persons who seemed in  tolerable  health, in a sudden  and  vio-
lent manner, like a common  inflammatory fever;  and,  like that, in
a little time bring them into imminent danger of their lives; after
which it has abated, and afforded hopes of recovery.  But the hopes
have been deceitful, for the hectic has still been fed by some lurk-
ing mischief; and, resisting the power of medicine,  has  gradually
undermined the patient's health and destroyed  him.
   More  commonly,  however,  hectic fever commences slowly and
insidiously, and is not suspected for  some months:  and  the  only
symptoms noticeable  are, lassitude upon slight exercise, loss of ap-
petite, and a wasting  of the flesh.  But if these symptoms be con-
nected with a general  increase  of pulse,  so that  the  artery  beats
from ninety to  a hundred, or a hundred  and  twenty strokes  in a
minute, there will be real ground for apprehension.
   This is one of many diseases in which the  art of medicine has
 hitherto laboured in vain to strike  into any direct  track of cure.
 The real cause is commonly involved in great and impenetrable
 obscurity, and we can do little more than attack single symptoms as
 they make their appearance.
   Where the disease is evidently symptomatic, the case  must de-
 pend upon curing, or, if incurable, upon removing, when this can be
 accomplished, the part affected.  Where idiopathic,  we must com-
 bat,  as far as we are able, the  irritable  diathesis;  and above all
 things endeavour to strengthen,  without increasing, the  action  of
 the machine.   The best  sedatives as well as tonics are acids, and
■ Trans, of the College, Vol. n. Art. i. p. fi. 
116                     HJiMATICA.           [CL. IH.-OR. I-
 of these the vegetable will usually be found preferable to the mine-
 ral,  since, on account of their corrosive  property,  the ^Jter can
 only be taken in small  quantities.  They abate the febrile  heat,
 diminish the restlessness, and frequently  succeed in checking the
 night-sweats.  And if, as is often  the case,  the patient be tormented
 with pains in the limbs or joints,  resembling rheumatism, and pre-
 venting him from sleeping, we may combine the acids with opium.
 The bowels must be  kept regular by gentle laxatives, and the neu-
 tral  salts seem to  in-wer this purpose better than most others.   It
 will, however, be convenient to  vary them occasionally, and some-
 times to exchange them for the  senna confection,  or  some other
 aperient.
  Stimulants rarely answer any good purpose ; and in many instances
 evidently heighten and accelerate the exacerbation.  The Peruvian
 balsam  has been given advantageously with nitre ;  but myrrh is a
 medicine of fairer promise ; and beyond these we can scarcely ever
 venture to proceed.
  The lighter bitters are certainly serviceable in many cases, and
 may  conveniently be employed in combination with the acids : but
bark, though tried in numerous instances, and with great perseve-
rance, has not been found successful.  Dr. Heberden,  however, says,
that he never saw it do any harm in the hectic fever, and his opinion
is confirmed by that of Sir Edward Hulse, after having prescribed it
for forty years.  Yet neither of them  ever obtained proofs of any
beneficial  result.
  A  light and regular diet,  regular hours,  and gentle exercise, are
 coadjutants of great  importance.  When   the  disease is dependant
upon some local affection, the Bath waters have often afforded relief;
but  in idiopathic cases they usually augment the fever, aggravate
 the patient's sufferings, and hasten his  death.
                     GENUS  IV.

                         ENECIA.

                    ttoutitmrti iPrter.

ONE SERIES OF INCREASE  AND DECREASE ;  WITH A TENDENCY TO EXACER-
  BATION AND REMISSION, FOR THE MOST PART APPEARING TWICE EVERY
  TWENTY-FOUR  HOURS.

We now enter upon the important genus of continued fevers, or those
which run their course, not indeed without  any change or relaxation
whatever, as many of them were supposed  to do formerly, and were
distinguished by the term continentes, but with occasional and slight 
GE. IV.]           SANGUINEOUS FUNCTION.               117

fluxes and refluxes, which bear the same proportions to the exacer-
bations and remissions of the epanetus as these do to the paroxysms
and intervals of the anetus or intermittent. When there are two tides
or fluxes within the twenty-four hours, the one occurs in the morn-
ing, and the other in the evening?  The  last is always the most dis-
tinct ; and takes place  usually between five and six o'clock,  which
is somewhat later than the latest  of the paroxysms of genuine inter-
mitting fevers; that of the quartan, which is the latest of the whole,
usually occurring before five o'clock. It should also be farther ob-
served that where continued fever discovers but one augmentation
in the twenty-four hours, it is always that of the evening.   Dr. For-
dyce attempts to show  that, even in a state of the firmest health, we
constantly discover some tendency to a little febrile affection every
evening ; this he calls the natural evening paroxysm of fever ; and
to this  habit he  ascribes the existence of an evening increase  of
continued fever.
   The genus, thus defined and characterised, includes the three fol-
lowing species :—
     1.  ENECIA  CAUMA.                  INFLAMMATORY FEVER.
     2.  ------  TYPHUS.#                TYPHOUS FEVER.
     3.  ------  SYNOCHUS.                SYNOCHAL  FEVER.

   Sauvages  draws  a line of distinction between these three  from
 their respective duration,  as well  as  from their more  essential
 symptoms, affirming  that the cauma terminates in  a week at the
 farthest; the typhus, in two, though sometimes protracted to three
 weeks;  while the synochus reaches beyond the second,  and  often
 beyond  the  third week.  As a general  rule this  remark is worth
 keeping in mind, but  the deviations from it in all the species, are
 too frequent to enable us to lay  hold of it in assigning their specific
 character.
                        SPECIES  I.

                   ENECIA CAUMA.

                   Euflammatorg iPefeer.

HEAT GREATLY  INCREASED ;  PULSE QUICK, HARD,  AND STRONG J  URINE
             RED J  DISTURBANCE OF THE MIND  SLIGHT.

This species has been distinguished by a variety of names by differ-
ent nosologists and other medical writers ;  the chief of which are,
imputrid synochus, which is that of Galen ; imputrid continued fever,
which  is that of Boerhaave ;  imputrid continent, which is that of
Lomniius ;  sanguineous continued fever, which is that of Hoffman; 
118                    HJEMATICA.            [CL. III.-'
and synocha, which is that of Sauvages, Linneus, Cullen, and most
writers of the present day.  Of these, svnocha, for reasons stated in
the comment to the  Nosological Synopsis,  is the worst; it has no
clear or correct etymological meaning; it has been used in ditterent
senses by different writers,  and approaches so nearly to synochus,
used as extensively by most of the same writers, as to create a per-
petual confusion in the minds of young students;  and the more so,
as the disease  before us is expressly denominated synochus by Vo-
gel, whilst most writers employ this term to import a different spe-
cies of fever.  On all which accounts 1 have judged it right to ex-
change synocha for cauma, a term already employed for the same
purpose by Dr. Young, and which, derived  from «*»$*,  " uro,   is
etymologically significant of the  character of the disease it desig-
nates.  The common English term inflammatory fever is excellent;
and is in truth a direct  translation of the Greek term cauma.  Dr.
Fordyce  denominates it general inflammation:  by which he clearly
intimates, that this species of fever bears a near resemblance to the
symptomatic fever produced by the local affections called phlegma-
siae, or phlogotica, which constitute the  next  order of the present
class, to which the term inflammations is now commonly limited; but
which Dr. Fordyce would distinguish by ther^erm " local inflamma-
tions."
   In effect, inflammatory fever  and the fever of inflammations bear
the same relations to each other as the idiopathic and symptomatic
hectic: in both there may be a general or a local remote cause, but
the influence upon the constitution will be the same,  whatever be
the source of excitement.  It has been doubted, however, whether
cauma or inflammatory  fever ever exists without a local  cause ; and
Dr. Cullen, who does not allow that hectic fever is ever found without
a local cause, distinctly affirms that he has never seen inflammatory
fever existing under the  same circumstances:  whence Dr. Clarke,
of Newcastle-upon-Tyne, who  has too much generalized  the sub-
ject, has struck  inflammatory fever entirely  out of the list of dis-
eases, contending that  even the term inflammatory ought never to
be applied to fever,  excepting when  fever itself only  exists as a
concomitant of some  local affection :* while Dr. Clutterbuck,  as we
have already observed,! has contended that  this local cause is at all
times, and  under every  variety of  fever,  an inflammation  of the
brain.   How far either hectic  or inflammatory  fever may,  under
particular circumstances of  humana or  atmospherical constitutions,
occasionally originate from marsh or contagious miasm, it is difficult
to determine; but as  Dr.  Cullen was peculiarly desirous of reducing
all fevers to these two sources, and as, to say the  least, they  are
not obvious sources  of either of the diseases in  question, his mind
appears to have received some bias from this fact, in rejecting them
from the list of idiopathic fevers.  And as it has already been shown

           * Observations on Fevers, &c. 8vo. London 1779.
           + Vol. h. p. 41. 
«E. IV.-SP. I.]
SANGUINEOUS FUNCTION.
119
 that this decision has laid a  foundation for much Of that " tug of
 war" in which many distinguished members of the profession have
 of late years been engaged, respecting the nature and treatment of
 particular species of fever, it is highly probable, also, that  several
 of the more recent hypotheses concerning its proximate cause have
 originated from the same spring.
   Inflammatory fever, as it has often occurred in the author's own
 practice, and in that of others who have  described it, usually com-
 mences with the Symptoms of an acute ephemera, and  may in fact
 be contemplated as the same  disease running on from  four or five
 to about eleven days without intermission, or a renewal of the cold
 fit.  It commences  with a sense  of languor and inaptitude for exer-
 tion, with a disrelish for food, which continues for a day or perhaps
 two.  There is  then chilliness  and soreness over the surface, with
 nausea and head-ache, succeeded in  the evening by a great increase
 of heat, and  at night by perspiration.  The bowels  are  usually
 costive, the urine high coloured, and the pulse quick and hard.
   With Dr. Fordyce the grand pathognomic symptom  of cauma is
 hardness of the pulse.  This  accompanies it from first  to last in its
 simplest and in  its severest state.  When the disease is mild, it is
 hard alone ;  when more violent, it is at the same  time full, strong,
 and frequent.   The obstructed pulse  is often confounded  with the
 hard, and it is not  easy to distinguish them  without considerable
 practice.  There is a rigidity of resistance to the  finger in  each,
 but of a different kind.  In the hard  pulse, it is much firmer  and
 tenser;  and is supposed by Dr.  Fordyce to result  from such an in-
 crease of arterial contraction as  to over-balance its  correspondent
 dilatation.   It indicates, in his opinion, a very high degree of living
 power, and is peculiarly characterized by a tardy coagulation of the
 blood when drawn freely into  an hemispheric bason, in consequence
 of which the red particles have time to subside,  and leave  the sur-
 face colourless or with a buffy appearance.  In the obstructed pulse,
 on the contrary, the blood coagulates at once ; and, the red particles
 not having time  to separate, the surface is of the same  hue as the
 cake below.
   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 medicina :  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-
• 
J20                     hjematica.            [cl. iil-or. i.
bid and increasing impetus ; but they do not all suffer alike :  for in
some parts there is, occasionally, a greater spasticity or tetanic re-
sistance in the blood-vessels, to "the flow o' 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 body 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, 
GE. IT.-SP. I.]
SANGUINEOUS FUNCTION.
121
jaundice 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 of the meninges of the  brain, by a lodg-
ment of vermicles in the frontal sinus, of wh ch  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 profunda, 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.
fi Biliosum.                       Accompanied with  an excessive
   Bilious inflammatory fever.        secretion of bile absorbed into
                                     the sunguineous system.
   Pleuriticum.                   Accompanied with a violent stitch
   Pleuritic inflammatory fever.       or pain in the side
3 Cephalalgicum.                 Accompanied with  acute pain in
   Cephalalgic inflammatory fever.    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  char-
 acter,  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 bv

                  * Mat. Med. in. p. 294.
   vor,.  n.                16 
122                    HiEMATICA.              [CL.HI.-0R, h

Dr. Fordyce, may then be employed with advantage.^ Of these the
tartarized antimony, the antimonial powder, or James s Powd^'^
chiefly to be relied upon; and may be  given alone, or,  which w
often better,  in  saline draughts; and particularly those formed oi
the acetate of ammonia.  And it may not be amiss to observe here,
that the acetate of ammonia is sometimes  prepared in the form oi
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
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. Fart 11. 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
ns, 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.

                      Egjinus iFetoer.

,mSE 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 ot
the fever to which it was applied at first5 and which it designates at 
124
HiEMATICA.
[CL. II1.-OR. I.
present; which burns, not with open violence as the cauma, but with
a sort of concealed and  smothered flame ;—for the Greek  term
ri*« signifies " to smoulder," or " to burn and smoke without vent
  Any of the ordinary causes of fever maybe a cause of typhus tor
the typhoid form  is often dependant upon the character  of the
constitution into which it is received, as evincing a great dehc.cncy
of sensorial power:  and hence  cold, mental  agitation,  exces.ot
muscular labour, and even intemperance, which m a high entonic
habit might generate synocha or inflammatory fever, will often in a
debilitated  constitution,  and  especially when the debility depends
primarily upon  the state  of the nervous system, and the nervous
fluid is recruited with difficulty, give a typhous  complexion to the
disease from the first.                                 .    .   ,
  But though all the  causes of fever may in this way give  rise to
typhus,  its common  cause, as we  had  occasion to  notice  when
treating of the remote causes  of fever,* is febrile mia^m,  issuing
from the decomposition  of human effluvium, under the influence ot
the ordinary auxiliaries  of a  close  and stagnant atmosphere ;  still
farther corrupted by a load of foreign  exhalations from  dirt  or hlth
of any kind, and of that degree of warmth and moisture  which must
always exist where society exists, and especially where it exists in
too crowded a state.  Under these general circumstances a very low
degree of warmth and moisture  is sufficient, though there must be
some proportion of both.  And  provided  there be an adequacy of
warmth, the lower the temperature, the more certainly an individual
becomes affected;  not from a more  abundant generation  of febrile
miasm, or from its being more volatile—for, on the contrary, it is
here perhaps  less abundant and  even less  volatile—but from the
more depressed state of  the living power, and the less resistance it
is capable of offering to  any morbid influence whatever.
  I have just remarked, that under  a depressed state of the living
power, whatever be its cause,  whether a want of cheerful warmth,
cheerful  passions,  cheerful food, or  cheerful  and regular habits,
typhus is often  more  likely to take place than  any other  species of
fever.  But when  febrile  miasm,  produced by  a decomposition of
effluvium from  the living body, exists  in co-operation with these, it
is almost impossible for  an individual to escape ; as the miasm thus
generated  has a specific  power—a  power beyond all other febrile
causes whatever—of lowering still  farther the vital energy as soon
as it is received into the system, and thus of confirming the previous
tendency to this peculiar type.
   All this indeed has been observed already, though it  is necessary
to  revert to it on the  present  occasion : it has also been farther
observed, that when  a typhus has in this or any other manner  once
arisen, the effluvium from the living body during its action is loaded
with miasm of the same kind, completely elaborated as  it passes off,
and standing in no need of the decomposition of the effluvium for its
        *
               * Vol. H. CI. in. Ord. i. p. 49. 
GE. IV.-SP. II.]        SANGUINEOUS  FUNCTION.             125

formation.   In many  cases, indeed, all the  secretions are  alike
contaminated ; and, hence, febrile  miasm is often absorbed, in dis-
section, by an accidental wound on the hand, and excites its specific
influence on the  body of the anatomist.
  Hence, typhus becomes infectious ; but as the miasm it generates,
though more suppressive or exhaustive of sensorial energ}',  is less
volatile than that of marsh-lands or dead organized matter, its infec-
tious  power is confined to a much more  limited atmosphere than
that  of fevers  originating from this  latter  source.  And, on this
account, fevers originating in jails,  or other  confined and crowded
scenes,  are  less  extensively communicable than the yellow fever,
or that of hot climates and exhaling swamps.
  It  may  be also necessary to recal the reader's recollection  to
another remark  that has  also formerly been made,  that in a pure
atmosphere, the miasmic  materials, from whatever source derived,
become dissolved  or  decomposed ;  but slowly and with great diffi-
culty, perhaps not at all, in a vitiated 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  where they  are  less  volatile,  as when issuing from
human  effluvium,  they perhaps adhere by  a peculiar tenacity  to
bodies more ponderous than themselves,  and thus  loiter for a still
longer period within the stratum of human intercourse.   And hence
the fouler as well  as  the  more stagnant the  atmosphere, the more
general, and, from the former cause, the more malignant the disease :
for as nothing is so contributory to the preservation of sound health
as pure air, so nothing tends so much as foul air to prolong or aggra-
vate diseases of  every  kind.  And hence, again, we have an obvious
and sufficient reason  why typhus  should  become  more severe  in
proportion as it spreads  and  impregnates a given space with  its
specific miasm and accompanying colluvies.
  To what extent febrile  miasm, issuing from the source before us,
may  spread in a  free influx of pure air without becoming dissolved,
or, in other words, so as to retain its contagious power, has never
been  very accurately ascertained.   We know, however, that,  its
range is  very  circumscribed,  and  reaches  to but a very  small
distance from the patient, or the nidus of 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.
Haygarth  has observed, in the patients own chamber, if large, airy,
and kept clean.
  It is  also of great importance to know  that typhous 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.   VVhen, 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. n. CI. I. Ord. I.  Sect. 9. p. 53. 
 126                     HJEMATICA.            [CL. IH.-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 vanes very
considerably in different individuals; and hence  we find that many
persons upon an equal exposure to typhous 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 ™ere
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, dependant
indeed, not upon the incidents  of more vigorous  health or higher
animal spirils, 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 haye 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 by degrees to endure poisons
of the most fatal power.  This we see daily in the use of opium and
ardent spirits ; and  we shall 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.
           t Essay on Yellow and Typhus  Fevers, p. 515. 
»E. IV.-SP. II.]      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 Ire 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.
   We  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 Carls-
crone,  or  at  least to have lingered there for four or five years  on
some occasions.!
   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:—
        x Mitior,                    Nervous fever.
       C  Gravior.                  Putrid  fever.
   The first variety, or mild typhus, was called by Dr. II xmhixm febris
lenta nervosa, and has hence been commonly distinguished by the
name of low or slow nervous fever, from the great languor and de-
jection of mental or sensorial power with which it is always accom-
panied, and on this  account it has sometimes been denominated the
hysterical fever.\  It is particularly characterized by slight shiver-
ings; heavy vertiginous  head-ache; oppression at the pracor-
  * Epanetus malignus asthenicus, Vol. ii. p. ill.
  t Foxe Neuen Schwed. Abhandl.  Band.  vm.
  X Manningham : on " The Symptoms, Nature, and Cure of the Febricula, com-
monly called the Nervous or Hysterical Fever." Lond. 1776. 
 128                      HEMATIC A.           [CL. IIL-OR. I.

 dia ;  nausea ;  sighing ;  despondency ; coma,  or  quiet  delirium ;
 whey-like urine.
   When the disease  appears  sporadically, it  is usuall/under this
 form.  There is  nothing alarming to the  patient's  friends on its
 accession.  The first symptoms are slight, the tongue exhibits tittle
 change, and the pulse is only a little quickened, and somewhat smal-
 ler than  usual: at the same time, however, there is great anxiety
 and depression of mind ; so that the symptoms do not much differ from
 a mild and  comparatively insignificant fever of any kind  operating
 upon a nervous temperament.   But as the disease advances, all the
symptoms of sensorial debility become severer ; the skin, which has
hitherto been mostly dry, will  about the third day be covered with
profuse, clammy,  debilitating  sweats, while the heat is  still incon-
siderable, and  the countenance pale and s«nk.   The sweat is often
offensive to the smell, frequently acid, and sometimes, according to
Stoll, as  sour as the  sharpest  vinegar.*  About the tenth day  the
weakness greatly  increases; all the limbs tremble ;  and the tremors
soon become convulsive, with a despondency and alienation of mind,
at first observable only in the night, but  soon continuing  with little
intermission: the  delirium is of the mild or quiet  sort, and  rarely
amounts to  phrenzy.
   The disease often runs on to  the  twenty-first day, and occasionally
to a much longer period.  It is seldom marked by that sudden change
which can be called a  crisis; but gradually becomes more aggravat-
ed in its symptoms till it reaches a fatal termination;  or slowly advan-
ces to convalescence,  by evincing  a disposition to natural sleep;
more steadiness and firmness of pulse ;  a more favourable  counte-
nance ; a tongue more florid at  the edges; a  firmer and more collect-
ed mind; and a returning desire for food, often indeed capricious,
but without nausea or sickness.
   In an anomalous and very singular case, related by Dr.  Satterley,t
the desire for food, which at  first  was greatly  loathed in whatever
form offered, reappeared about the fifth day with an enormous crav-
ing which it was impossible to  satisfy.   Animal food was preferred,
but food  of  any kind  was swallowed voraciously; and  when food
was not allowed, various indigestible substances were devoured in
its stead.  This desire returned with every  returning ingravescence
of the fever, which adhered  to no  regular period ;  and it continued
as long as the ingravescence lasted, which was usually ten or  twelve
hours.   The disease extended  with numerous variations to upwards
of thirty days, when the fever  unequivocally subsided, and the pa-
 tient gradually recovered.
   Of the treatment we shall speak, after considering it in  its severer
 forms.
   The heavier, severer, or putrid typhus  chiefly  differs from the
mild in the  violence and rapidity of its inarch,  and  the marked and
* Rat. Med. m. p. 79.
t Med. Trans. Vol. v. Art. xxn. 
Gtj. ir.-SP. II.]      SANGUINEOUS FUNCTION.              129

undisguised character it assumes from  the first.  While the mild
therefore commences insidiously With only slight shiverings, the
heat scarcely above  the  natural temperature, and the pulse small,
and only a  little quickened, the heavy typhus opens with sensible
and alternating rigor and heat, succeeded by little or no perspira-
tion ; the pulse is tense and hard, usually quick but fluttering; pain
over the forehead and crown; urine alternating from limpid to tur-
bid ; delirium succeeded by stupor, and early signs of putrescency.
  From  the last feature, the disease has derived its common name
of putrid fever ; as it possesses the additional names of  jail, camp,
and hospital fever, from its appearing so frequently in these situa-
tions,                                                  ju
  During the first twenty-four hours the alternate heat and cold are
considerable ; the fever increases every  evening, and in  the second
week  the  delirium usually commences ;  the stupor  following hve,
six, or seven days afterwards.   From  the first  there  is a violent
head-ache and vomiting;  the pain over the forehead  shoots  through
the eyes to the bottom of the orbits ; the eyes themselves are lull,
heavy, and slightly inflamed ; the countenance is bloated ; the tem-
poral  arteries throb,  while  the pulse at the wrist is small; the  ears
tingle ;  and the mind, antecedently to the delirium, is fearfully de-
 IGCtCcl.
   The balance of the sanguiferous system is generally much distur-
bed, from  a greater degree of sensorial debility in some organs than
 in  others;  and hence, the blood is determined irregularly, and ac-
 cumulation, affusion, and inflammation are frequent effects.   1 hese
 show  themselves  chiefly in the head, the lungs,  and the liver;  but
 there is no organ in which they may not occur ; and they never can
©ccur  without danger.  If no critical change take  place about the
fourteenth day, leading distinctly to an amended state, the symptoms
of  putridity increase both  in number  and  degree ; there is great
faintness ;  difficulty of respiration, intermixed with deep sobs ;  the
breath is hot and offensive; acute pains in  the  loins and  limbs;  a
 heat upon the skin biting and pungent, rather than burning, leaving
 a smarting sensation on the fingers for several minutes  after touch-
 ing it, and which from this very peculiar effect has been called calor
 mordicans.   The tongue, whitish at  first, is now  dry, dark, livid,
 black, or  of a  pomegranate  colour.  The lips  are furred with a
 black tenacious  sordes; the  urine becomes brown or blackish wi h
 a most offensive smell; a blackish or  bilious matter is occasionally
 thrown up from the  stomach;  the skin is more  or less  discoloured
 with  flea-bite-shaped or broad purple spots; the  stools are blackish
 and  highly fetid.  Cold, clammy, colliquative sweats  and convul-
 sions, sometimes accompanied  with hemorrhage from one or more
 organs, soon afterwards usher in death; the period of which is ex
 tamely uncertain, and ranges from the  fifth to the eighteenth day,
 according to the malignity of the attack, the  strength of the patient
 or other contingent circumstances.
    From the  purple  or  flea-bite spots,  which last  are  often called
    VOL. II.                     l7 
 130                     HiEMATICA.             LCI" m--°R' !"

petechia?, or as it  should rather be written petecchiae, this'variety
has been verv generally treated of on the continent under the name
of febris petechial,  or petechizans;  sometimes, as by  foliini  anu
Matarasi iST under that of febris peticularis ; sometimes, as ny jaco-
bi and  Morelkt  it has been called  febris purpurata; while ny  a
Castro it is termed febris punctularis ;§  and by De Cermona, febris
cum punct<dis.\\   By the Spaniards, it  was  hence vulgarly denomi-
nated tavardillo or tabardillo, from tavardo, a spotted cloak former-
ly in common use.   ! hese punctae or vibices, however, are nothing
more  than  symptoms  of putrescency;  and are common to other
fevers, and  even to  diseases, without fever, as land or sea scurvy
(porphyra hemorrhagica  and p. nautica) as  well;  and hence  have
no ground whatever for establishing a distinct species, and still less
 a distinct genus.
   I have said, that the milder  variety or nervous  fever  usually
shows itself sporadically,  originating from some  other cause  than
febrile miasm in an irritable and atonic habit. Malignant typhus some-
times commences in the same  way,  but  usually by a decomposition
 of human effluvium accumulated in a camp, a ship, or even a large
 single family, when  the space is too small for the number, the hab-
 its uncleanly, and the atmosphere stagnant and unventilated.   The
 cause  is one, and the fever the same, varied alone by accidental cir-
 cumstances,  or  symptoms that depend  altogether upon  its less  or
 greater degree of violence.
   In  this metropolis,  therefore,  malignant  typhus is  almost exclu-
 sively to be  met with amongst  the  poor; and  the more  wretched
 and destitute they are, the  more readily they become its  prey.   I
 cannot better illustrate its rise and progress, than  by  the following
 simple picture as furnished by Dr. J. Hunter: it is drawn from life,
 and will be easily recognised by every practitioner.
   " A poor  family,  consisting  of the husband, the wife, and one  or
 more children, were  lodged in a small apartment, not exceeding
 twelve  or fourteen  feet in length, and  as much  in breadth.  The
 support of them depended on the industry and daily  labour of the
 husband, who with  difficulty could  earn  enough  to  purchase food
 necessary for their  existence;  without  being able to provide suffi-
  cent clothing or fuel against the inclemencies of the season.  In or-
  der, therefore, to defend themselves against the cold of the winter,
  their small  apartment was closely shut  up, and the air excluded by
  every possible means.  They did not remain long in  this  situation
  before the air became so vitiated as to affect their health  and pro-
  duce a fever in some one of the miserable  family.  The fever was

   * Orationes de Natura febris peticularis.  Colon. 1722. 8vo.
   t De Febribus peticularibus malignis, contagiosis, &c.  Mezarini, 1722.  8vo.
   X De Febra purpurata epidemica.  Lion. 1641. 8vo.
    i Febvis maligna punctularis aphorismis delineata.  Tub. 1G93.
    || Tract, de Peste et Febribus cum punctulis.  Sevilla 1581. 8vo. 
GE. 1V.-SP II.]
SANGUINEOUS FUNCTION.
131
not violent at first, but generally crept on gradually;  and the sick-
ness of one of the family became an additional reason for still more
effectually excluding the fresh air;  and  was also a means of keep-
ing a greater proportion of the family in the apartment, during the
day-time ;  for the sick person was necessarily confined, and another
as a nurse.  Soon after the first, a second was  seized  with the fe-
ver; and in a few days more the whole family perhaps were at-
tacked,  one after another, with the same distemper,  i have oftcn-
er than  once seen four of a family ill  at one time, and sometimes
all lying on the same  bed.   The fever appeared sooner or later  as
the winter was more  or less inclement;  as the  family was  greater
or smaller; as they were worse or better provided with clothes for
their persons and beds, and with fuel; and as their apartment was
more or less confined."*
   There are a few auxiliary causes not noticed in the above faith-
ful delineation, which seldom fail of being present, and have always
a very considerable degree of influence; these  are, the anxiety and
dejection of mind so sure to accompany  such a scene of misery, and
the increasing carelessness and consequently uncleanliness of person,
which are equally sure  to follow.  And  we may hence see why ty-
phous should so frequently make its appearance in the poorest and
most miserable streets of a metropolis, and be generally confined to
such streets : why it should rage most extensively and most violent-
ly in times of the severest public pressure and  distress;  and hence
again why it should  be more common  in Ireland than in  England,
in Dublin than'in London.   We also see the inestimable  advantage
of such establishments as Fever Houses or Infirmaries  in all popu-
lous towns, when built upon the sound principles, and governed  by
the judicious regulations, and, 1 may add,  superintended by  the ac-
tive humanity and established talents which are so conspicuous  in
the Fever Hospital of this metropolis.
•   To describe  the  typhus of jails, ships, camps, and other large
bodies of men, we have only to multiply the single fam'ly we  have
just beheld into  fifties or hundreds; ever remembering, that the
virulence of the febrile poison increases in power, not in a nume-
rical, but in a sort of geometrical  proportion  to the numbers  by
which it is fed.  So that if  five patients produce a given ratio  of
pestilence, ten will produce, not as  much again, but  nearly  a  hun-
dred times as much.  And hence we may readily account for the
fearful and deadly ravage which this cruel scourge is  well  known'
to inflict upon a people  when closely pressed together, and incapa-
ble of flying from its  pestilential aura, as in crowded encampments,
or a besieged and pent-up town;  and especially  where,  as  is  often
the case, there is considerable carnage from the casualties of war,
and a deadly calm prevails for weeks together  in  the  atmosphere.
This last concomitant, indeed, gives completion to the whole ; and
  * Observations on the disease commonly called the Jail or Hospital Fever.  By
John Hunter, M.D. Physician to the Army.  Sec Med. Trans, Vol. in. Art. xxn. 
132
FLEMATICA.
[CL. III.-OK. I.
is a heavier calamity than it is generally conceived to be ; for the
most fatal pestilences of which we have any  account  seem to have
been preceded by a  stagnant atmosphere.  Thus  Maitland, in his
History of London,  observes, that for several  weeks  before the
plague broke out in this  metropolis in 1665, there was an uninter-
rupted calm, without sufficient  motion in  the air to  turn a vane.
The assertion  is  confirmed by  Baynard, a contemporary physician :
and a like harbinger, as  is  observed  by  Diemerbroeck,  preceded
the plague at Nimeguen.
  In both  varieties, the prognosis must be collected from the vehe-
mence of the symptoms, and the character of the idiosyncrasy ; and
the cure must depend upon the means we may possess of supporting
the vital power,  and restoring its lost energy.
  The peculiar properties by which typhous  miasm is distinguished
from miasms of every other  kind, are the rapid and direct debility
with which it affects the  nervous system, and seems to prevent  a
due secretion of nervous  fluid, or its secretion in a state of health-
ful elaboration ;  the activity of its leaven, by which  it assimilates
all the fluids of the body  to its own nature, and  the urgent putre-
factive tendency it gives  to every part.
  The last of these properties may in  some  degree  be dependant
upon the first; but it does not  appear to be entirely  so;  since we
often find  the sensorial power reduced to a much  lower ebb,  as  in
asphyxy from  hanging or drowning, suffocating exhalations or light-
ning, catalepsy, and deliquium from loss of blood, while there is an
almost infinitely  less degree of tendency  to putrefaction.   And,  in
like manner, although the miasms of many  of the exanthems, as ro-
salia or scarlet-fever,  small-pox and plague, are also capable  of
tainting the secretions of the body, none of them appear to do it  so
completely and universally as that of typhus  when in  its  most ma-
lignant state ;  in which the breath, all the egesta, and all  the  fluids
are loaded with  contagion.   It has been propagated by the excre-
ment,* by the odour of flowers employed to decorate  the dead bo-
dy ;T by washing  the  bandages employed in typhous  gangrene,f
and, in innumerable instances, by the  communication  of  a minute
drop of any of the fluids  of the dead body to  a punctured  finger du-
ing dissection.
   In forming our prognosis, and attempting a cure, these properties
should always be prominent in the mind ;  for they will best enable
us to calculate the nature and  result  of symptoms that are present
and will guide us to  the  most rational and satisfactory mode of prac-
tice.
   From the debility that prevails throughout the living fibre, even
from the  first, the pulse  is feeble and tremulous, the  extreme  ves-
sels torpid or  nearly so,  and the circulatory balance greatly disturb-

           * Riedlin, Lin.  Med. 1695. p. 402.
           t Eph. Nat. Cur. Dec. Ann. vn. vni. Obs. 193.
           % Hennen's Principles of Military Surgery, p. 218. 
GE. IV.-SP.  II.]        SANGUINEOUS FUNCTION.             133

ed.  Hence, we have reason to expect that effusion and congestion,
or an irregular determination of the blood, will in many cases bean
early attendant: and, if there be energy enough remaining in the
organs thus  affected to produce any degree  of reaction, that  local
reaction will follow, and perhaps lead to inflammation  terminating
in suppuration or gangrene ; of which Sir John Pringle has given
numerous examples.  And hence there is some ground  for contem-
plating typhus, as Dr. Armstrong has done,  under the  three varie-
ties  of a simple,  congestive, and inflammatory affection.  But  it
should never be forgotten, that the disease in every stage and vari-
ety is one and the same ;  a disease of sensorial debility  leading on
to putrescency; and that our only  hope of cure depends on econo-
mizing the  nervous power that remains, supporting it  as far as we
are able without farther loss, and opposing the natural  tendency  of
the disease  by such tonics as the system will best bear.
   On this account whatever tends  to weaken the animal frame ge-
nerally, or any one of its  functions particularly, must, as a common
rule, be carefully abstained  from: and  hence  severe evacuations,
by bleeding or purging, are  among the foremost objects of prohibi-
tion.
   The bowels, indeed, ought by all means to be moved by a gentle
 aperient, in order that no acrimonious material may be lodged there;
 but beyond  this we ought not to proceed, as we shall add to the de-
bility without obtaining any correspondent advantage.  The grate-
ful acids of tamarinds, cream of tartar, or prunes, are  preferable, if
found sufficiently powerful;  but, if not,  they  should  be combined
with  rhubarb or senna.   And as the stomach is less irritable than  in
yellow  fever, an emetic  may  be  given  whenever indicated ; but
unless there be a troublesome nausea, even this had better be avoid-
ed.   Ipecacuan  will  answer better  than antimonial  preparations,
and the evacuation should be followed with  a cordial draught.
   But congestion, as already observed, may  take place, and this too
in the larger and more  important  organs of the animal frame,  as
the head, the lungs, or the liver.  If in  the first,  there will  be a
sense of oppression in the  brain,  most  commonly  combined  with
stupor, or low muttering  delirium ;  if in the  second,  a  laborious
weight on the chest and a difficulty of respiration;  if in the third,
 the bowels will usually be found costive, the motions  pale   and ar-
 gillaceous, and sometimes the skin and the urine chlorotic,  or of a
greenish-sallow from  a regurgitation of bile, morbidly secreted, in-
 to the sanguineous system   Hence  the fever will be aggravated
 from local irritation,  and  the affected organ will  be in danger  of
inflammation if not of gangrene.
   Is  the general rule in this case to be  departed from ? is  blood  to
be taken from the system ? and, if so,  is it  to  be  drawn locally or
generally ?  and to what amount ?
   We have here only left to us  a  choice of difficulties.  Nothing,
as Dr. Fordyce has justly observed, is more dangerous in any fever
than its  affecting one part more than another; but in typhus the 
134
H/EMAT1CA.
[CL. III.-OR. I.
 danger is extreme ;  and it must be combated boldly  and rapidly by
 whatever plan has a chance of taking it off, and however hazardous
 in itself, provided the hazard be less than that of the disease.   And
 hence, in this case, bleeding must be had recourse to,  for  there is
 nothing we can so well  depend upon.   If we have reason to believe
 that the overloaded organ is without inflammation, the  blood should
 be drawn locally  and till relief is afforded ; if there be  good ground
 for suspecting that inflammation has commenced, and  especially if
 the organ affected be large and important, it will be better to  em-
 ploy the lancet; and it cannot be employed  too soon,  nor  ought it
 to be relinquished till it has attained its object.   There is a risk in
 the practice, but  there is death without it.  Fainting may  perhaps
 take place in the  midst of the operation ; but this is rather  to be
 wished for than guarded  against; for the exhaustion  of sensorial
 power produced  by deliquium bears no comparison  to that produc-
 ed  by  the  influence of  the  typhous miasm,  acting  as a leaven
 throughout the system.
  In this state of  the disease, also, instead of merely  keeping the
bowels open, we should employ purgatives that  may stimulate and
 maintain a stimulating effect upon the whole  of the intestinal  canal,
so far as that three or even four evacuations may be obtained daily;
and calomel will be commonly the best  medicine  for this purpose.
 For such an irritation will frequently prove revellent;  and the drain
 of sensorial power hereby produced will be  trifling  in  comparison
 to that occasioned by a continuance of  the local excitement it is in-
 tended to remove.
  Such are the exceptions, and the only ones, we  should allow to
 the general rule of opposing the disease, by economizing,  support-
 ing, and  restoring the depressed tone of the  nervous system.   But
 there are pathologists, and of considerable authority,  who recom-
 mend bleeding, and even full bleeding, in almost every instance of
 the disease, as the first step to be pursued : thus inverting the mode
 of practice here laid down, and taking  the exceptions for the  rule,
 and the rule for the exceptions.
  The  theory of this  recommendation  is but of little importance
 provided it be justified by its result.   At the  same time  I cannot
 avoid observing, that its chief advocates have not been able to bring
 themselves to any thing like a common theory, or to support their
 recommendation upon common principles: than which nothing can
 be more unfavourable to the reception of a doctrine, or more hos-
 tile to  its scientific pretensions.  Typhus is,  by Dr.  Clutterbuck,
 regarded like every other kind of fever, as the result of an inflam-
 mation of the brain;  and blood-letting is here grounded upon  the
 principle of attacking the cerebral inflammation, and debilitating the
 action of the living fibre.   The visceral and other local congestions
 and inflammations that so  often occur, are,  by Dr. Armstrong * re-
 garded as precursive and generative of the sensorial debility, while

             * Practical Illustrations of Typhus, kc. 8vo. 
GE. IV.-SP. II.]        SANGUINEOUS  FUNCTION.             135

the disease itself is no more derived from the brain than from any
other organ.  And blood-letting,  under this view of the subject, 1%
recommended as the means of preventing debility in  the living fibre,
instead of adding  to it.  " We may  perhaps find,"  says he, " suffi-
cient data for concluding that the  nervous appearances,  even from
the  very  first attack, are only secondary  of vascular disorder."
Now, these  hypotheses,  discrepant  as they  are from each other,
may be  both founded upon a mistake of the effect for  the  cause.*
And such, indeed, seems to be the general opinion of  pathologists
upon the  subject; and hence, even admitting the benefit of blood-
letting as an invariable or common rule, we have yet to search for
some other reason  by which such  benefit is  to be  explained.   Dr.
Jackson thought he had found this reason in the stimulant effect of
venesection upon  the  system at large, which, by exciting new mo-
tions, suspends or changes morbid  motions, and affords room for the
vires medicatrices naturae to act with a more salutary power: while,
by its mechanical effect in diminishing the circulating fluid, it adapts
the  moles movenda  to the  vis  movens.  Venesection, therefore,
upon Dr. Jackson's hypothesis, acts not by debilitating, or even pre-
venting debility,  but  directly by invigorating the living fibre : and
in this  view he employed it in fevers of every kind,  entonic and
atonic; inflammatory and putrid ;  and, in his own belief, with nearly
eflual success.
   But this is to regard the blood as an incumbrance,  a dead and
foreign body in its own  vessels, instead  of  as a living and nutrient
principle ;  the removal of which affords ease and freedom to every
part of the animal frame,  and clears it for the contest in which it is
about to engage.   A violent and general commotion produced in the
system  from severe bleeding, or any other cause, cannot fail of ex-
citing a very deep impression  upon every part; and has often sus-
pended or changed the actual train of motions, and introduced a new
train in its stead; and, in various instances,  the change has unques-
tionably been beneficial  and even salutary.  This is  particularly*
the case in  sudden and overwhelming excitements of mental emo-
tion, whieh have, sometimes, abruptly cut short the career of fevers
 as  well as of various other  complaints; of which the Baron Van
 Swieten gives a  striking instance in a man, who,  while labouring
 under a continued fever,  with delirium, was so alarmed at  the ter-
 rific aspect  of a person that burst suddenly into the  sick room, voci-
 ferating that the house was on fire, which in this case was the fact,
 that he rose  without help from his bed, ran out of the house with
 all speed, and was well from that moment.   To this principle of  a
 salutary change of action  excited  by a violent and  general commo-
 tion throughout  the system,  it is  probable  that we  are to ascribe
 the occasional benefit that has followed upon draining the vessels
of blood in  diabetes and  even in lyssa, or canine  madness.  And  it
is possible,  therefore, that copious venesection may, also, in man^
* Appendix to his Remarks on the Constitution of the Medical Department. &*<•. 
 136                     HiEMATICA.              [CL. IH-OR. I-

instances, have cut short the attack of typhus,  and thus' P«>^ J
rapid and effectual remedy.   But if this be the ground upon which
it acts, few practitioners would be disposed to recommend it, while
if it be  not, we  have no other ground that will furnish us  with a

SaBuUt0h7vralre\ady°nobserved  that the  theory is of little impor-
tance provided the practice has justified itself by the event   How
then stands the sum of general opinion  upon  this subject,   ine
practice is, by no  means, new, though ordinarily supposed to be ot
recent origin:  for it has alternately  lived and died away,  been re-
vived and again sunk  into disrepute, for considerably  upwards ot
three centuries ;  and its advocates have, in various times,  been as
numerous and as confident, and have maintained as warm a contest,
as we are called upon to witness at present:  ot which any one may
convince himself who  will turn to the books referred to  in proof ol
this assertion at the  foot of the page ;* of which the first  three were
published in  the sixteenth century,  the ensuing two in the seven-
teenth, and the last two in the middle of the eighteenth.  The work
of Professor De Biichner, of  Halle, was strenuously opposed in his
recommendation of  venesection, at Paris  by Chambon de Montaux,
and at Rome by Sinibaldi.  Yet, as in the present day,  the suppor-
ters of the depleting system had also not a  few controversies amongst
themselves, though  they were not precisely of the same description
as those in our own time ; the chief point of dispute  being the part
of the body from which blood could be drawn with  most advantage;
some practitioners performing on the arm, and others on the leg or
 foot;  a point, however, that gradually lost its  importance, as the
 doctrine of the  circulation of the blood became  more generally
 adopted and understood.
   Judging, therefore, of the expediency of blood-letting from the
 history of the practice before us, when enforced as  a  general rule
 in typhus, the sum of medical opinion upon a trial of three cen-
.tiiries is against  it.  The  practice  has  occasionally started  into
 popularity, but it has  never been able to establish itself.  In the
 peculiar states of the  disease I  have already adverted to, it may be
 useful, and ought not  indeed to be neglected :  but every case must
 speak  for itself, and the rule must not be confounded with the ex-
 ceptions.  And such, in effect, was the opinion of Dr. Gilchrist, as
 expressed in  his treatise  on Nervous  Fevers, published  seventy
 years ago, in  which he tells us, that at  that period  " the ordinary

   * Bernauli Caxancs, De Ratione mittendi sanguinem in Febribus putridis, Bar-
 celon. 1592.
   Sylvaticus, De secanda in putridis Febribus,  vena quam Salvatellam  dicunt.
  1583.
   Thurini, An in oinni Febre putiida rompctat phlebotomia, Rem. 1545.
   Nia;risoli, Progymnasma de vena in Febre maligna secanda,  an superior! an h\
  feriori.  Guastalla,  1T65.
   Suavalla, Ergo malhnae febri vensesectio, Paris, 1694.
   De Biichner, Diss. d» Vnu sectione in fcbru acutis malignis, Halle, 1757.  .
   Gilchrist, Edin. Med. Essays, Vol. iv. Art. xxui. 
GE. IV.-SP. II.]
SANGUINEOUS FUNCTION.
137
evacuations in the beginning were bleeding and vomiting," and that
it was  sometimes " necessary to  bleed  once, and again, by which
the symptom'* were considerably lessened."*  But he had too much
good sense  to enforce this practice indiscriminately,  and felt  the
necessity  of yielding to  contingencies:  for in  many  instances, he
adds, " though we bleed, the symptoms are not always much abated
by it;  and if  we bleed freely, being deceived by an appearance of
plethora, we  do harm:  indeed, in general,'1 continues he,  " I im-
agine bleeding seldom did much good; and if great caution were not
used, I suspect it was hurtful: but as 1 was not  often called  in the
beginning, I am unwilling to pronounce positively about it."  The
passage is  weil worthy of  attention, as containing the  tree opinion
of an able, candid, and  distinguished writer upon  an  extensive ex-
amination of the subject in his own day:  and an opinion, too, which
is very considerably in accordance with the opinion and practice of
Sir John Pringle and Dr. Huxham.
   It should never be forgotten,  however, that the  expediency of
bleeding  must depend,  not only on  the diathesis of the individual,
but very considerably on the state of the atmosphere.   This remark
I wish to enforce very strongly on the attention of practitioners, as
it is derived  from experience, and is of more  importance  than  it
may at  first  perhaps appear  to be.  As  inflammatory fever  has,
sometimes, a  tendency from peculiarity of constitution or accidental
circumstances to run rapidly  into typhus; typhus, in like  manner,
occasionally meets  with incidents that suddenly reverse its  charac-
ter and incline it to  an  inflammatory type.  A very stimulant plan
of treatment  has sometimes done this;  but far more  frequently  a
sudden change in the atmosphere,  from  hot,  hazy, and  relaxing
weather, with scarcely a breath of air stirring abroad,  to a dry, cool,
and refreshing east or north-east breeze  :  and I have  often  found  a
like tonic effect produced upon a patient  labouring under typhus in
a low, damp, filthy, and suffocating lodging, upon his being removed
into a large, cool, pure, and well-ventilated chamber, such as is now
generally found  in  our  fever  institutions.  In this case, bleeding,
which I had  not dared to risk, notwithstanding some symptoms of
oppression, before the removal,  has  been practicable  without any
risk afterward^, and  has laid  the  foundation of a speedy  and effec-
tual cure ; and I  am inclined to think that some part of the  clash of
opinion,  which prevails  upon this subject in the present day,  pro-
ceeds from a want of due attention to the different states in which
different or even the same patients are placed  by this difference in
the  purity and temperature of the surrounding atmosphere ; and that
many hospital-physicians, who are the warmest advocates  for  san-
guineous depletion in their own fresh, cool, airy wards, would hesi-
tate upon its expediency if they were to attend their patients through-
out in their own close, heated, and miserable habitations.
   It is only a few months ago that i was consulted  by a very re-
            * Edin. Med. Essays, Vol. iv. p. 281.
VOL.  II.                   18 
138
HiEMATICA.
[CL. III.-OR. I.
spectable practitioner in  Hertfordshire, upon a plan of treating ty-
phus, which was then raging with great  violence among the poor
of the town in which he resided.   He had  been a surgeon in the
naval service of the East  India Company : and having witnessed the
benefit of early and copious bleeding in the yellow fever, had very
generally  followed it  up in  the  contagion before him, and, as he
frankly confessed to me,  with a decidedly unfortunate  result.  My
advice was. before he thought of the lancet to take care of the ven-
tilation ;  and then  to subject it to the restrictions here  laid down,
and to let every case be its own interpreter.   And a letter received
from him a few weeks afterwards expresses  his obligations  for the
advice, and the success that had resulted from it.
  Upon this subject  there  is a passage in Dr.  Hennen's  Military
Surgery so  strikingly in point that 1 cannot avoid quoting it.  After
thelfamous battle of Vittoria, in July 1813, the sick and wounded of
the British and Portuguese  army were  chiefly  removed to a tem-
porary hospital established at Bilboa; where typhous miasm having
soon been produced by its ordinary causes, of a foul and  stagnant
atmosphere, crowded  wards, and depressed spirits, the sick were
soon affected,  and  whatever was the nature of the individual con-
stitution, the wounds of all of them ran rapidly  into a typhous gan-
grene ; " exhibiting," says Dr. Hennen,  " one of the most subtile
and  destructive poisons  that ever infested an  hospital,  attacking
equally the most robust and the most debilitated, and, if unchecked
by  medical aid, proceeding invariably  to  a  fatal termination."*
The atmosphere was, at  this time, sultry  and relaxing ; and greatly
contributed to  the general  debility.  " I need  scarcely say," con-
tinues Dr.  HennenJ " that a remedy so strongly recommended  as
venesection had early occupied  our attention :  but previous to the
month of October  the obviously  typhoid type of the  disease made
us extremely averse from employing it.  At that period, however,
a change in the weather from sultry to  cold,  and  even frost (at
night) took place,  marked  by a corresponding change in the ther-
mometer, which, at  its medium  range,  was 20° lower than in the
preceding  month.—But  what more than all convinced  us of  the
change of  tvpe, and pressed on  our consideration  the propriety of
blood-letting, was,  that the spontaneous hemorrhages which former-
ly sunk the patients strength were now  accompanied with obvious
relief."  And he proceeds  to state that from this time the practice
of venesection, on the appearance of inflammatory  symptoms in a
wound or  newly-healed  stump, became general, and was the only
remedy had recourse to whether  as a cure or a  preventive.
   Of such  importance is it for  us to be guided by  particular  and
general circumstances in  the treatment,  not merely of typhus, but
of all diseases  whatever:  to let  the rule have its exceptions, but
not to mistake  the exceptions for the rule.  " The art of physic,"
* Principles of Military Surgery, p. 19.
+ Id. p. 223. 
GE. IV.—SP. II.]     SANGUINEOUS FUNCTION.
139
says Sir George Baker, " rarely admits of any perpetual precepts;
and the  best medicine  may do harm  if not adapted to  the patient
as well as to the disease."*
  There is another  remedy of very  extensive use in  the cure of
typhus,  far less disputable, and which is  founded altogether upon
the indication of equalizing, supporting, and restoring the sensorial
power:  and that is, the free application of cold water, and especial-
ly externally.
  This valuable medicament has been employed in some form or
other almost immemorially.   Hippocrates recommends  it in malig-
nant fevers generally in  the  form of  epithems, or  napkins wetted
with  cold  water and applied  repeatedly to the  head or any other
viscus as the cloths became warm.t  Among the  later Greeks, how-
ever,  it does  not  appear to have been in  very general use ;  and
though it is highly prized by Celsus,  in various debilities,  and es-
pecially sensorial  debility affecting  the head, and combined with
fever, in which, says he, " existat validissime repente aqua frigida
infusa,"| yet it does not seem  to have constituted a fixed, or even
a frequent practice in his day.   In our own country it was success-
fully  employed  by Dr. Willis, in  various fevers,  and especially
those accompanied with delirium ; and was hence strongly recom-
mended by  Sir J  Floyer and Dr. Baynard: and was used on the
continent,  not merely in the form of epithems,§ and affusions, but
occasionally in that of immersion, or cold bathing in a river adjoin-
ing the patient.||
  On the continent,  indeed, it  seems  to have  been  employed at a
much  earlier period than in  our own country, as we learn from
Milot's Dissertation, " Ergo febris frigidis et humidis expugnenda,"
printed  at Paris in 1594;  and  Hernault's, on  the  same  subject,
" Ergo propria febrium medela  refrigeratio," printed in the same
place in 1630.   It was also used internally as well  as  externally,
both in our own country as well as on the  continent, especially in
Spain and  Naples, as is  obvious from Dr.  Hancock's Febrifugum
magnum,1T and Dr. Cyrillo's paper on the subject in  the  Philosophi-
cal Transactions.   Even snow,  or snow-water,  under the name of
aqua nivata, or aqua nive refrigerata, was also occasionally employ-
ed ;** and, in the ardent fever, recommended by Paullini both ex-
ternally and internally tt  And to prove how torpid to common im-

  * Med. Trans, ni. 417.
  t ITsjj Nouow, ii. p. 484. 50.
  X Medicinse, Lib. in. Sect. xx.
  } Mursinna iiber Ruhr und Faulfieber. Loeffler, Beytrage, &c.
  || Eph. Nat. Cur. Dec. m. Ann. in. Obs. 48, and Ann. v, vi. App. p. 128.
  f Febrifugum magnum : or common water the best cure for fevers.  Lond. 1752,
  ** Nouvelles Annales de Medicine, iv.
  tt Cent. 1. Obs. 66.
  See also Nehemias (Abrah,)  De tempore aquae frigidae in febribus ardeptibus
ad satietatem exhibendae. 8vo.  Venet. 1591.
                                                        Planchon, 
 140                     1IEMATICA.            [«- IH.-OR.  I.

 pressions the body is under  nervous fevers generally, and how lit-
 tle disposed to be injured by such applications, it is only necessary
 to advert to the case of a patient at Lucca, given by L»r. J._r»ene-
 vuti, in another part of the  Transactions just  referred to.  un ine
 ninth and tenth day from the incursion of a malignant fever, ne was
 thought to be in great danger.  On the eleventh,  he "pressed a
 wish  to go  to sleep, and desired the attendants to withdraw.  On
 their return, he was found to have  left  his bed;  and three days
 afterwards  was discovered  in a hut in a vineyard, about two miles
 from the house, having but  just recovered his senses, and as much
 wondering  how he came there as those  who had traced him out.
 It appeared, on farther inquiry, that he  had descended from his
 chamber by the window, in  his shirt alone, and in a great perspira-
 tion ; had walked  all the way in the  snow with which  the ground
 was then covered,  and had swallowed  a  large  quantity of it to
 quench his thirst.   Yet neither the cold air nor cold beverage af-
 fected  him  otherwise  than  beneficially.  He  continued well from
 this time.*
   The use  of cold water, however,  as well external as internal, ap-
 pears on many  occasions to have  been  employed  with too little
 caution, and hence one reason of its falling into  frequent disrepute.
 Even as early  as 1581, Masini thought it right to guard the pro-
 fession against its abuse,  by a work expressly devoted  to this sub-
ject ;t and  numerous others occurred in  succession through the
 ensuing century.
   In our own day, Dr.  Wright of Jamaica is, perhaps, the first phy-
 sician who  revived the practice ; but it is chiefly to the judgment
 and experience, the writings and recommendation of Dr. Currie of
 Liverpool,  that cold water as an external application is indebted for
 the high and deserved  degree of popularity it again possesses, and
 especially in typhus.
   It is now equally used in  the form of sponging, ablution, and af-
 fusion, the last  of  which is the xxrxxXvns of the Greek  writers,
 though the  term occasionally  also imported immersion.  All these
 are  of essential use ; yet  the most  sudden  and decisive benefit
 has been observed  to result from affusion ;  for which purpose the
 patient is to be supported on a stool in a low wide tub, and to have
 a small bucket of water, containing about two gallons, poured brisk-
 ly on his head, and repeated four or five times in the course  of the
 twenty-four hours, when the surface of the body is hot and without
 perspiration.  In many cases this plan alone has proved successful,
 and the fever  has  been cut short in  a day or  two from its com-
 mencement.  But the  method is  two violent and  exhausting to be
 employed after the first three  or four days of attack ; beyond which
  Planchon, Journ. de Med. Tom. xxx. p. 127.  Lamarque, id. Tom. txvi. 460.
Lxvii. 68.
  ' Phil. Trans, vm. 1768.
  t De Gelidi Potus abusu. 4to. Cesen. 
GE. IV.-SP. II.]      SANGUINEOUS FUNCTION.
J41
it will generally be  most useful  to restrain  ourselves to epithems
about or all  over the  head, the  hair being  removed for this pur-
pose, or sponging the body generally : and if the sensorial debility
be extreme, we should prefer tepid to cold water, or mix with the
cold water a little brandy or other spirit.  When this method suc-
ceeds, the usual salutary effects are,  a considerable diminution in
the number of the pulse  ; diminution of heat and head-ache ; natural
sleep, and a breathing perspiration.
  It does  not appear to me that the principle has yet been fully ex-
plained by which the external application of  cold  water becomes
thus  unequivocally  beneficial.  This  is  generally  referred  to its
tonic power in  exciting a  reaction as the  result of its  chill.  But
though affusion often  produces not only  a chill, but even horripi-
lation, sponging the body with tepid or even with  cold  water pro-
duces no  chill of  any kind ; and there are many cases of extreme
debility  in which, if a  chill  were to take place, it would be most
mischievous, and  certainly  would not be succeeded by any heat or
reaction whatever.  Independently of which, the refreshment takes
place too speedily for such  an effect, and is of a different and more
tranquillizing kind than  the excitement which follows upon the chill
of cold bathing in a state of health.   And I cannot, therefore, but
think it probable  that much of the good  effects of  the external ap-
plication  of cold water in typhus  and other complaints depends
upon a decomposition of the water;  though whether by an absorp-
tion  of caloric or  of oxygene, alone  or in conjunction  with any
other principle hereby set free, is  by no means  easy to determine.
There is yet much to  be learnt upon the cause of that beneficial
excitement which the decomposition of water  exhibits in various
bodies, both organic and inorganic, with which it comes in contact.
We see  plants instantly  revived, the fire in  the  blacksmith's forge
instantly  quickened, and not only tile-eels  and  other animalcules,
but even  snails, apparently  dead, and  that have been kept as dried
preparations  from  five  to  fifteen  years,* start instantly into new
life upon the application of cold  water.   Yet no chemist or physio-
logist has hitherto satisfactorily explained by what  means these ef-
 fects are  produced.   And I  throw out the hint, that  so instructing  a
 subject may be followed up by those who have time and  ingenuity
 for experiments in relation  to it.
    Upon internal medicines  we can place  but little dependance, ex-
 cept where they have pretensions to a tonic power, are  moderately
 cardiac, or tend to equalize the sensorial or  circulating  fluid.
    The chief tonics  in use among the Boerhaavians were the ser-
 pentaria and contrayerva, on account  of their  systematic objection
 to  the bark.  The tonic power of these,' however, is  but  feeble;
 by their  stimulant property, they sometimes prove diaphoretic: but
 even as cardiacs their place is better supplied  by other medicines;
 and in proportion as the bark has established itself, they  have gra-
* Spalanzani, Hist. Nat. Tom. n. ch. iii.  Phil. Trans. 1774, p. 432. 
142                    HiBMATICA.             [CL*  nI*  '
dually fallen into disrepute.  Yet even this last seems to be follow-
ing the same track in the opinion of some practitioners of the pre-
sent day, who have withdrawn all confidence  in  it, and undertake
to affirm  that it has uniformly done more mischief than good,   but
this is strangely to set  aside the wisdom of former  times, and to
misconstrue the train of phenomena before them.   Bark, like every
other medicine, is necessarily injurious when injudiciously made use
of; but there are few, if any, medicines of more importance, even
in typhus, when there is a fit opportunity for employing it.  Where
the stomach  is irritable, and will not retain it, or so feeble in its
secernent power as not to digest it, and, particularly, where there
is a tendency to local accumulations,  it ought  unquestionably to be
avoided,  till  these  symptoms are  subdued by  other means.   But
where there  are no such objections it cannot be begun too  soon,
though it should not be pressed in such large doses as in the  more
rapid course of yellow fever.  And where the bark cannot be made
to sit easy on the  stomach, its place may be well supplied with co-
lumba, either in powder or infusion.
  If the  skin be greatly heated and dry, either of these  medicines
may be combined with nitre or a solution of the  acetate of ammo-
nia, the first of which was a favourite compound with Baron Haller
and his disciples ;*  and if the prostration of  strength be considera-
ble, we may employ camphor or wine in conjunction with tonics.
  Camphor has, indeed, been united  with medicines  of  very  diffe-
rent powers; as with large doses of nitre which Haepel seems to
have found highly serviceable;! or nitre and calomel, which was at
one time a favourite practice in Germany ;J  or, which is far better,
with cinchona, a combination peculiarly recommended by Lasonne
as increasing the  energy of each, in  which opinion he is joined by
Dr. Cullen.  Camphor, however, is in itself a highly valuble medi-
cine on the present occasion, and cannot well be  given tco soon.  It
calms the low delirium, produces a genial glow on the surface, and
seems to act as a steady, permanent cordial.
  In our own country, however, it is rarely employed in doses suf-
ficiently  large to  be of service,  as I  have  already  had occasion to
observe.   Giseke was accustomed to begin with half a drachm, and
increase  the dose to a drachm, three or  four times a-day  or often-
er.§  It was given with equal freedom by Stoll,|| Salle,1F and Cham-
bon de Montaux :** and Collin  after several  hundred trials affirms,
that he has never in a single instance found the pulse quickened, or

  * Haenel,  Epist. ad Haller.
  t Epist.  ad Haller, H.
  % Abhandlung von der Wirkungen des Camphors und Calomels in anhaltcnden
Fiebern.
  i Abhandlungen, &c.
  || Rat Med. m. 89.
  tf N. Britrage, i 171.
  ** Traite de la fievre maligne. 
GE. IV.-SP. II.]      SANGUINEOUS  FUNCTION.              143

the heat of the body increased, by giving it to the  amount  of half
an ounce a-day.   It has by many practitioners been united with some
acid ; and in the form of an acetum camphoratum, was atone time a
very favourite, and no doubt effective, medicine in Germany.*
  Acids, indeed,  of all kinds,  and acidulous drinks,  are of great
benefit  in typhus.   They allay the heat,  tranquillize the restless-
ness, support the strength, and oppose  the tendency to putrescency.
The muriatic was preferred by Sir William  Fordyce, but the sul-
phuric appears to be equally efficacious, and is much  pleasanter.
  The best  cordial is  wine, and it must be  given in  proportion as
the living power flags.   We must  be cautious, however, in first ad-
ministering it; for its very stimulus produces exhaustion, and con-
sequently increased torpitude :  and we should invariably  recollect,
that when we have once commenced with  its use,  we  can never
leave it off;  and should hence begin with such doses only as maybe
safely persevered in, or even increased if necessary.
  Under the  influence of Dr. Brown's name,  both wine and spirits
were lately given in enormous  quantities ; and it is possible  that in
a few instances the practice may have been successful: but the risk
is great and empirical; yet by no  means of so late an origin as Dr.
Brown's name would incline us to  believe :  for Borelli, Chambon de
Montaux, and Reidlin gave it quite as  largely, and  at least with as
much success.   Borelli prescribed it in injections ;t Reidlin assures
us that  he cured a patient by administering a large dose of spirit of
wine,| upon which Brown does not  appear to have ventured; and
we are told by another writer long before Dr. Brown's time, that he
completely succeeded in conquering a typhus by making his patient
drink wine to ebriety on a critical  day.§  Of phosphorus, which was
also a famous cordial at one time,  I can say  nothing.||
  The same  remark will apply to the  use of opium, which appears,
in many cases, to be of less service  in typhus  than in many  other
species of fever, and by no means  entitled to  the unmeasured eulo-
gy bestowed  upon it by Dr. Home,  who contended that in every
case of typhus it was the most useful medicine we  can have  re-
course  to; that it  procures rest  without any inconvenience ; and
that it is more to be depended upon than camphor, castor, the seda-
tive salt of Homberg, or any  other medicine  of the same  class.1T
It is best given in combination with  camphor;  and there  is ground
for the  assertion of Lasonne and Halle, that, thus united, it  produ-
ces less confusion of the  head and  disturbance in the  dreams : and,
  * Ludvvig, Adversaria, I. i. N. 1.  Bonnevault,  Hantesierk Recueil, II. p. 228.
  t Cent. I. Obs. 55.
  X Lin. Med. 1695. p. 220.
  } Eph. Nat. Cur. Dec. I. Ann. m. Obs. 145.
  ||  Vater, Diss. Phosphori loco medicamenti adsumpti virtus medica.  Witteb.
1751.  Thomas, Diss.de usu Phosphori. Regiom. 1762.
  V Clinical Experiments, Histories aud Dissections.  8vo. Edinh. 1780. 
144
HjEMATICA.
[CL. III.-OR. I.
so far as I have seen, it agrees better with the  young  than  with
those of middle life.
  Antimonials are a doubtful remedy : they  tend  to throw the ac-
tion towards the surface ; but, as relaxants, they  tend  at the  same
time to  diminish the  tone of the muscular fibre.   It is not often that
they can be employed with advantage.  Blisters,  judiciously  inter-
posed, will be found, in many instances,  a useful  auxiliary, and es-
pecially where the head is much affected ; but the body  should not
be covered over with them, as is often the case  from head to foot,
so as to  be highly distressing to the patient,  and  to  exhaust the lit-
tle irritability he has left.  Cataplasms or bottles of hot water ap-
plied to the feet, when the circulation is unequal, will  often  be a
better practice.
  Yeast, as an antiseptic, was  strongly recommended to  be  taken
into the stomach by many practitipners about twenty or thirty years
ago, and numerous cases were  published of the wonderful  cures
which it performed.   Of late  it seems to  have fallen into an unme-
rited neglect: it is a simple remedy, easily procured, and worth a
more  general trial.
  During the entire  course of the  fever, from the time the bowels
have been sufficiently evacuated, the patient may be allowed animal
broths and jellies in  alternation with  the  farinacea: he should  be
lightly covered with  bed-clothes ;  his chamber should be freed from
all unnecessary furniture; his sheets and  body-linen be  frequently
changed, and be instantly taken out of the room;  as should also the
egestions of every  kind.
  Above all things the chamber should be freely ventilated, which
is infinitely the best way of purifying the air,  and dissolving the
febrile miasm as it issues from the body : upon  which subject we
have already touched.   Where the ward  or chamber  is large, or
the sick are remote from each other, simple ventilation by opening
the opposite windows, or the  windows  and door, will  be sufficient.
But where the wards are small, or may not admit of sufficient ventila-
tion, or  the patients are numerous,  fumigation with nitric or muriatic
acid should not be neglected.  At  present we have no  reason  for a
preference, except  that the  vapour of the former appears  to be
rather more volatile and penetrating.  Of late  years  there  have
been attempts to decry the use of fumigations, and especially by M.
Von Mons and Dr. Trotter, who conceive that  they rather add to
than diminish the septic matter of the  atmosphere.  On which  ac-
count they rather advise to sprinkle the  room frequently with wa-
ter, and maintain a  good fire, believing  that  febrile  contagion is
much better destroyed by pure aqueous vapour than by any  other
means.
   But this conception is founded upon a double hypothesis, and an
hypothesis apparently  mistaken upon both points: first, that febrile
miasm,  and septon,  or  the elementary  matter of putrescency, are
the  same thing: and, next, that this  common principle  is nitrous
oxyde,  or oxyde of azote,  agreeably to the  conjecture  of Dr. Mil- 
GE. IV.-SP. II.]      SANGUINEOUS  FUNCTION.              145

chell.  Of septon, however, we know but little ; yet from the es-
tablished power of hydrogene in exhausting or destroying  animal
irritability, it  is more  probable  that  M.  Morveau's conjecture of
its being a combination of hydrogene with azote rather than of oxy-
gene with the  same, is the  real fact.  But be  this as it  may, we
have no more  reason for believing  that febrile miasm consists of
either of these, than  that it consists of animalcules of a peculiar
kind, as was once contended for by Dr. Chandler.
  Febrile miasm  we have reason to believe is  a peculiar and spe-
cific production ;  the chief properties of which I have  already en-
deavoured to point out.   Pure air unquestionably dissolves it; and
hence there may  be other gases  capable  of dissolving it  also, and
even more readily; or which, combined with pure air, may render
the latter a speedier and more powerful solvent.  And it is proba-
ble that the vapours of the mineral acids act  in this manner.  In
this respect they  may be useful; but if ever employed to supersede
ventilation, the opinion of Dr. Trotter that they do  more mischief
than good will be completely established.   The aromas  of volatile
plants are of no benefit whatever;  and if the fumes of tobacco were
ever serviceable  in the plague, it was most probably, as Dr. Cullen
conjectures, from their exhilarating the spirits  like wine or  opium,
and diminishing the irritability.
                        SPECIES III.

                 ENECIA SYNOCHUS.

                     Sgnochal jFefcer.

COMPOUNDED OF CAUMA AND TYPHUS : IN ITS COMMENCEMENT RESEMBLING
            THE FORMER ; IN ITS PROGRESS THE LATTER.

It is not necessary, after our copious histories of the two preceding
species, to follow up the present, which is a mixture of both, through
a detailed description of its course.   It is  certainly the most com-
mon form under which continued fever makes its appearance in our
own country ;  for it is but rarely that cases  of fever  occur which
preserve a strictly  inflammatory character from the beginning to
the end.  It is in fact an inflammatory fever bent out of its proper
career, often, perhaps, by the temperament upon which it  has to
act; but still more frequently, as Dr. Brocklesby has well observed,
by confined and vitiated air,  and hence dropping its inflammatory
pretensions in the middle of its course.  Its causes are therefore the
same as  those  that produce  inflammatory  fever.  Dr.  Cullen has
entered it into his catalogue of genera after Sauvages and Linneus;
but with a doubt whether he  is correct in so doing.  " Since many
  VOL. II.                     19 
140
HJEMATICA.
[cl. Hi.-OR. t
fevers," says he,  « are neither altogether inflammatory, nor alto-
gether nervous, they cannot be referred either to the synocha. (cau-
ma) or the typhus : and I have hence  inserted ^e genus synochus
whose type is frequently seen in this country   Yet  between the
typhus and synocha I cannot place any accurate limits ;  and   doubt
whether they should in fact be deemed genera  or have a different
place allotted them."  And in his First Lines he  observes,   I am
disposed to believe that the synochus arises from the  same causes
as the typhus, and is therefore only a variety of it.    1 o me it ap-
pears rather to arise from the same causes as the cauma, tor it com-
mences with the cauma-type.   The proper rank for  all  of them
appears to be that of species; and the present system in the text-
book, in allotting  them this character, steers just a  middle course
between Dr. Cullen's actual arrangement and his real opinion. And
in this view it is  distinctly regarded by Dr. Stoll, who sometimes
describes it as an inflammatory fever assuming a putrid guise; some-
times as equally inflammatory and putrid ; and sometimes as an in-
flammatory fever passing into  a  sahurral fever.*  By  Kausch, and
other German pathologists, it is hence denominated febris inflamma-
torio-putrida.t It is, in many instances, the inflammatory typhus of
Dr. Armstrong.
   Occasionally it shows  a considerable tendency  to terminate  its
course abruptly by a  critical sweat; it is sometimes peculiarly mark-
ed with yellowness of the skin ; sometimes with great stupor of the
head ; and sometimes with inflammatory tension of the peritoneum.
And it hence furnishes us with four varieties :
x Sudatorius.                     Carried off by a critical sweat
  Sweating synochus.               in an early stage of its progress.
€ Flavus.                         With yellowness of the skin, at-
   Yellow  synochus.                tended with a  sense of burn-
                                   ing heat.
y Soporosus.                     Accompanied  with  stupor from
   Comatose synochus.               the  beginning.
3 Puerperarum.                   Accompanied  with an inflamma-
   Puerperal fever.                 tory tenderness of the belly:
   Child-bed fever.                  mostly occurring on the third
                                   day after child-birth.
   The symptoms of the first variety open with  great violence.
There is  usually an intense  pain in the  head with  a vehement
vomiting  and purging, which is rarely removed, and sometimes aug-
mented, by an emetic: the skin is peculiarly dry and hot.  The
balance of the circulating system is here greatly disturbed, and there
is an evident  determination  of blood to the head,  and  probably
to the liver.  Like the yellow fever, it rushes forward rapidly to a
state of great sensorial debility ; and is best checked in its progress

                * Rat. Med. m. p. 97. 106. 113. iv. 61.
                 t Gruner, Almanack, 1788. p. 37. 
GE. IV.-SP. FT.]      SANGIIVEOUS FUNCTION.              147

by a free use of the lancet,  which more than any thing else takes •
off the tendency to congestion, and the hardness from the pulse.  A
diaphoresis commonly breaks out soon afterwards,  which proves
critical, and should be maintained by diluent drinks, and small doses
of antimonials or other relaxants.
  In the yellow-tinged synochus there is a high degree of hepatic
irritation, and  consequently an excessive secretion of bile, part of
which is resorbed and carried into the  system :  whence Galen de-
nominates  it synochus biliosa.*   It is found chiefly in the summer
season among young persons of a bilious habit, and is  generally pro-
duced, like the genuine cauma, by too violent exertion under a sul-
try  sky.  It is accompanied with intolerable thirst and sleeplessness.
in few words, it is a  causus or ardent fever without any  apparent
remission;  its symptoms, with this exception, are the same, and the
same mode of treatment is  demanded :  for which  the reader may
turn to the second species of the preceding genus.
  While the symptoms rage violently,  there is  sometimes a  great
determination to the  head,  with  a sudden exhaustion of  sensorial
power; and  hence, notwithstanding this local affection is  more se-
vere  and confirmed than in the first  variety,  there is a dull and
obtuse, rather than an intense and pungent pain.  It is the  synochus
soporosa of Guarinon  and  Sauvages; and  the continual  fever of
Sydenham  for the year 1763.  Among the chief symptoms, says he,
was a coma,  for the patient  soon became drowsy and obscurely de-
lirious.  Occasionally, however,  it was a  direct  lethargy, which
continued for two or three weeks, during which nothing but  a vio-
lent noise would rouse the  patient; when after opening his eyes
and being persuaded, perhaps, to take a little food or some medicine,
he again fell  into a sleep so profound, that Sauvages calls it a febrile
cataphora.   In  some  cases, however,  instead of a lethargy, there
was a low muttering delirium, in which the patient spoke incongru-
ously and with fretfulness, with short snatchings of stertorous sleep in-
terposed.   The fever rarely terminated in  less  than  fourteen days;
and, when  the  lethargy prevailed, generally ran on  to  twenty-one
or even thirty days.   The first symptom of recovery was  usually a
capricious  longing for some absurd  kind of meat  or drink.   The
head for many days still  discovered great  weakness,  and  even the
muscles were incapable of supporting it  in an erect position. Warm
cordials  were always  mischievous: a free and repeated use of the
lancet with brisk  purgatives formed the best plan  of cure,  with
diluting  diaphoretics  afterwards.   Sauvages asserts,  that blistering
the head was serviceable.  Epithems of ice-water over the whole
head, repeated as soon as they become warm, would  probably have
proved far more beneficial,  as soon as the vessels of the head had
been sufficiently emptied.
  We find  the same fever  still more frequently commencing with
a like tendency to the peritoneum instead of to the hea*', which runs
* De Differ febr. cap. n. De Crisibus, cap. n. 
148                     MMAT1CA.           tCL- llI-°R* L

rapidly into  a state of inflammation, with an imperfect att®™P* **
suppuration; and especially  where this  membrane has oeen«xu
ed by a sympathetic action with the uterus or any other adjacent or-
gan, or by exposure to the atmosphere in consequence ot a wouna
through the  abdominal integuments.  And hence this disease occurs
occasionally  in  cases of tapping for a dropsy of the abdomen, and
still more frequently after  labour: on  which account it  is  com-
monly known by the name of peritoneal, puerperal, or child-bed
fever.  From the days of Hippocrates to those of Boerhaave and
Van Swieten, the uterus was supposed to be the chief seat ot inflam-
mation when the disease  arises from  this cause.   But there is now
no question that it originates in the  peritoneum itself, and that the
uterus is often very little affected; and this too, though the inflam-
mation should spread, as it often does, to other organs in the vicinity.
  The  disease  usually commences about the third day  a.ter de-
livery, or a  wound made  through the abdominal integuments by ac-
cident,  or in tapping for a dropsy of the abdomen ;  though some-
times it occurs  rather later.  It is marked by all the common symp-
toms of a severe febrile incursion, in combination with the tenseness
and tenderness of the belly.  The muscles of the back and hips are
in great pain; and as  the diaphragm is affected  by contiguous sym-
pathy, the breathing is also  short and laborious.   The head rarely
suffers much at first, but in the progress of the disease is apt to be-
come stupid and comatose.   The flow of the milk and of the lochia
are suspended: the stomach is sometimes, but not generally, troub-
led with sickness, and frequently discharges an offensive porraceous
suburra; and a troublesome  diarrhoea attacks the bowels.
   To account for the inflammation of the peritoneum, it is only ne-
cessary to recal to mind the  readiness with which, in particular con-
stitutions, or states of excitement from various internal or external
causes, inflammation often takes place in interior cavities, and the
rapidity with which it spreads  over every part of them.  It is to
this principle alone we trust in effecting a radical cure for a dropsy
of the tunica vaginalis of the  scrotum.  The cavity here is  small,
and we are  not afraid of serious mischief;  but were it as  large as
that of the peritoneum, he would be a bold operator who should ven-
ture upon a  like mode of cure,  notwithstanding that the process of
adhesion, so much more easily effected in the scrotum than  in the
abdomen, might diminish the chance of danger.
   In the opinion of Mr. John Hunter, the disease  takes place in con-
sequence of an injury done to the peritoneum, as forming a cavity,
by which its present state is either suddenly changed or rendered
imperfect.   The injury  done to the peritoneum in the case of wo-
 men after delivery, he ascribes, as his sentiments are delivered by
Mr. Cruikshank, to two causes.   Sometimes it proceeds from a want
 of disposition in the womb to recover itself after labour;  by  which
 the peritoneum, as a cavity, must necessarily be  affected.  At  oth-
 er times from  a too sudden emptying of the abdomen ; whence the
 peritoneum cannot always recover itself so as to be properly  adopt- 
GE. IV.-SP. HI.]
SANGUINEOUS FUNCTION.
149
ed to its new condition.  This last cause, he observes, may also hold
with men after the operation of the paracentesis.  But, in them, be-
sides the  sudden emptying of the abdomen, there is the additional
circumstance of a wound, which renders the peritoneum, as a cavity,
imperfect.  When an  inflammation  of the  peritoneum  occurs,  it
most frequently happens, as he still farther remarks that it spreads
over all the cavity of the abdomen.   An extravasation of fluids takes
place into that cavity mixed with pus.   The different viscera ad-
here by their peritoneal coats.  The intestines are distended with
air.   And the irritation, thus induced, kills the patient long before
granulations or an obliteration of the cavity in the  second  method
can occur.*
  Neither of these two causes, however,  by themselves will often,
if ever, produce the fever before  us, or even peritoneal inflamma-
tion alone.  For the uterus is perpetually exhibiting a morbid en-
largement, without a disposition to recover itself; and the abdomen,
sudden evacuation, while no such fever ensues.  There must co-ope-
rate a peculiar temperament, or a peculiar condition of body at the
time ; and, in puerperal patients, there is especially the general pyrec.
tic excitement which necessarily follows, upon the very great change
in various organs which takes place upon delivery and the transfer of
accumulated action from one organ to another.  Another accessary is
also frequently found  in  the constitution of the atmosphere ;  for
whatever change is  most calculated to produce fever from a morbid
excitement of the abdominal viscera, cannot fail to  co-operate  in
the production of this  disease  from  a local cause.   I have  already
observed that such a  change most  usually occurs  in autumn, and
have stated the grounds on which it depends under  the history of
epanetus  aittumnalis, to which the reader may turn at his  leisure.!
And hence, so far as I have  observed, a tendency to peritoneal  or
puerperal fever occurs more frequently at this season than at any
other; and on this account it is said  by some writers to occur occa-
sionally as an epidemy.J  There is much  reason, indeed, for regard-
ing it in this last view; for as  most of the auxiliaries that unite  in
the production of contagious miasm  are present in a lying-in cham-
ber, such miasm is frequently the result; often indeed, as we have
reason to believe generated, after the manner of typhous miasm,
and completely elaborated in the circulating and secreted fluids  of
the  patient herself.  Of this fact there can be  no longer any ques-
tion, after the accounts of  the  disease published by Dr. Gordon  of
Aberdeen, and Dr. Young  of Edinburgh, as it appeared in the lying-
in infirmaries of these  cities;  in which woman after woman conti-
nued to be infected to a very great extent, and especially wheret hey
had had close communication with puerperal patients, or had even
been attended by nurses or midwives who had previously attended
* Edin. Med. Comment. Vol. ill. 322.
t See Vol. n. CI. in. Ord. I. p. 93.
t Clark, Edin. Med. Comment. Vol. in. 
150                      HEMATIC A.           0L-  ^I•-,
the latter without sufficiently changing their malignant dress.  This
disease was only subdued by the ordinary means employed to exter-
minate contagious miasm, such as great cleanliness, repeated change
of sheets and body-linen, free ventilation, and a total separation  oi
those who were labouring -under the disease from those who  were
about to be confined.
  In all kinds of contagious fevers  we  find that some persons are
more liable to be  infected than others from incidental circumstan-
ces; and, as I have already had occasion to observe in laying down
the laws of febrile miasm so far as we are at present acquainted with
them, the miasmic corpuscles are modified in a few of their proper-
ties by the accessaries to which they are exposed, or by which they
are produced.  And by bearing these  facts in mind, we shall have
no difficulty in accounting for the limitation of this contagious fever
to puerperal women, and the  exemption possessed  by persons who
are not under the same circumstances.   For, operative as the miasm
unquestionably is when the predisposition exists, and the abdominal
organs are thrown  out of the balance of healthy action, it is inert
where no such predisposition is to be found, and these organs are in
elastic vigour.
  But whether the miasm thus  generated be  the  common febrile
miasm we have contemplated in several of the preceding species,
merely modified in its powers by accidental circumstances, or a con-
tagion specific and peculiar to itself, is a question which, at present,
we have not the means of determining.
  I have said that in the inflammation which takes  place,  there is
an imperfect attempt at suppuration.   The fluid secreted or effused
is usually a whey-like material, or  milky ichor, or, as  Mr. Cruik-
shank has  described it, an   extravasated matter  mixed with pus.
But Dr. Hulme* asserts, that he  has  sometimes found genuine  pus
apparently secreted without ulceration;  and Dr. Meckel informs
Baron Haller,  that he  has witnessed the same very extensively.t
The nature of the fluid will, indeed, entirely depend upon the vehe-
mence and  rapidity of the  inflammatory process.   Where tljis is
less violent, the secretion, as from the  surface of other mucous mem-
branes, may be purulent  or even genuine pus, and has sometimes
amounted to  several pints; but, where  more violent, it will  be
a milky, caseous, or whey-like  serum.   It is rarely  however so
mild and temperate in its march as to produce pus; often running
on, as Dr. Hulme has observed, to a state of gangrene  at  once :
and in some  instances  has  been found  to  involve  the  intestines,
omentum, and all the neighbouring viscera, in the common mis-
chief, as has been  abundantly established by post-obituary examina-
tions.;}:  And hence, the uterus itself has sometimes participated in

           * Treatise on the Puerperal Fever.
           t Epist. ad Haller Script. Vol. m.
           X Hulme, ubi supta.  De la Roche, Rccharches, &c. 
GE  IV.-SP.  III.]      SANGUINEOUS  FUNCTION.             151

the inflammation, and has shown pus or gangrene according to the
vehemence and rapidity of the morbid influence.*
  The general treatment of this disease should very closely resem-
ble  that already laid down for the severer varieties of the malignant
remittent, which  it very much resembles, with the  exception that
the fever is  continual instead  of being relaxant; and that the local
irritation is  seated in the peritoneum instead of in the liver or any
other organ.   This inflammation must be subdued, and that speedi-
ly,  or the patient will perish; and hence,  abstraction of blood and
calomel purgatives are the arms  on  which we have chiefly, if not
solely, to depend ; and both should be employed decidedly, and to as
great an extent as we dare.
  Eighteen  or twenty ounces of blood  should be drawn  from the
arm, as soon as  possible  after the commencement  of the disease,
and repeated  within  twelve hours if necessary, and  the strength
will allow :  but if venesection have not taken place before the third
day, the debility  will have gained so  high an ascendency, and the
general symptoms put on so putrescent a complexion, that little be-
nefit is to be gained  from it.   The bowels should at the same time
be moved by six or eight grains of calomel given in  the form of a
pill;  and  the same  preparation,  to  the amount  of three  or four
grains, should be  continued every six hours till the tension and sore-
ness of the abdomen have abated.
   It happens not  unfrequently, however, that the patient's frame is
so weak and delicate that  we  should risk more by drawing blood
generally than even by leaving the case to nature ;  as it does also
that the stomach and bowels are from the first in a very high degree
of irritation, with violent purging  and  vomiting, and will not bear
any additional stimulant.   Our wisdom  is  here  to yield to circum-
stances, and let the general rule admit of particular  exceptions.  In-
stead of the  lancet, we have recourse to leeches, and in this manner
remove twelve ounces of blood at the least; and with smaller do-
ses of calomel we must unite opium.  It does not follow  that calo-
mel in such  a  combination will increase the irritation of the stomach
or bowels ;  I have often seen the  contrary ; and that by the exhibi-
tion of two grains with one grain of opium, repeated every five or
six hours, the irritation has yielded to the commencement of a new
action. Warm and anodyne fomentations to the abdomen are usual-
ly  prescribed  at the same time, and are often found  palliative ; but
 the common mode of applying them makes the bed wet and gives
great  fatigue  to  the  patient.  And hence, I  have  ordinarily pre-
scribed a large piece of folded flannel wrung out forcibly in  as hot
water as can be borne, to be applied over the whole  of the pubes
and abdomen, and covered by a broad flannel or linen swathe pass-
ed under the  loihs and folded over the epithem of reeking flannel,
which is to  remain for many hours, or till it becomes dry.  All that
is wanted in this  application, as in a common bread-and-water poul-
* Bang, Act. Soc. Haffn. I. 
152
HjEMATICA.
[CL. M.-OR. I.
tice, is warmth and moisture; the  flannel answers the Panose  as
well as the bread; and whilst I do not recollect a single instance^in
which this application has not been soothing and ^serviceable, 1 have
never met with a case in which a chill has been complained of.
  In the mean time, a diapnoe or breathing perspiration °n the sur-
face should be attempted by small doses of ipecacuan  united with
opium in the form of Dover's powder, and with  h\addltlon °f.a
solution of acetate of ammonia;* and if the debility be very cons -
derable, we may employ free doses of camphor, beginning with half
a scruple, and proceeding to half a^drachm at a time, every four or
five hours, with great advantage.                             .
  If this plan should not answer,  and the skin be  still hotter, drier,
and more pungent to the touch, the pulse quicker and more wiry,
and the tongue deeper  furred, it may be  adviseable to  exchange
epithems of hot for those of cold or even ice-water, as already re-
commended in cases  where the head  is chiefly affected  instead of
the peritoneum.  I freely confess  that I  have not tried this plan
myself hitherto,  but  it  is strongly recommended by Loeffler  and
other physicians of great repute; and as it is a practice in common
use in our own country in the case of flooding, without any evil re-
sulting from it, we have no reason  to expect  any evil  in the case
before us; for the sensibility is  here still more  obtunded than in
flooding, and nearly as much as in deliquium.
* Beytrage zur Wondarzneykunst. Band. i. 
CLASS  III.
H^MATICA.
                        ORDER II.


                    PHLOGOTICA.

                      Inflammations.

fixed heat and pain or soreness; increased  secretion; lesion  of1
  a  particular part or organ ; mostly accompanied with fever.

The diseases comprised under this order  are  sometimes called Lo-
cal  Inflammations ;  as the term General Inflammation is, by a few
writers, and particularly by Dr. Fordyce, applied to Cauma or  In-
flammatory Fever.  In  the  present text  the  ordinal name made
choice of is phlogotica, from ?Asy*», " incendo," " ango."  Linneus
employs phlogistica from the same  root;  but as the chemists have
long since laid hoW of phlogiston, and the term, though lately dis-
used, has  a chance  of being  restored, the derivation phlogotica
seems preferable.   Dr. Cullen has phlegmasia,  after Galen and Sau-
vages ; but as phlegmasia, and phlegmatic, from  the same source, im-
port, in common medical language, a very different and almost an op-
posite idea, the author has also purposely  passed by this term in  or-
der to prevent confusion.  The nature of the  fever accompanying
the inflammation cannot enter into the definition;  for this will vary
v/ith the nature of the inflammation  itself, and not unfrequently with
the structure of the organ.  But we  may make  this observation,
that the symptomatic cauma, or  symptomatic  inflammatory fever,
seems to Lave followed the fortune  of this fever  in  its idiopathic
state ;  and to be as much less common in the present day, compared
with what it was formerly, as we had  occasion  to  observe the sim-
ple cauma is when treating of that disease.  Such is also the  remark
of Mr. Hunter.  " I  believe," says he, " we have  much less  occa-
sion for evacuations  in inflammation than there were formerly; the
lancet, therefore in inflammation,  and also purgatives, are much
more laid aside.1'*
           * On Blood and Inflammation, p. 227.
vol.  N.                  20
• 
154
HjEMATICA.
[CL. IlI.-OR. II.
  When an inflammation  takes place near the surface of the body,
(here is not only heat and pain, or soreness, but more or less swell-
ing,  hardness, and redness,  and  we  hence infer the  existence of
these last symptoms in inflamed parts which lie beyond the reach ot
vision.
  Inflammation in most cases appears to begin at a point; for, at the
commencement, all the local symptoms are within a very small com-
pass.  The spreading of the inflammation is owing to continued sym-
pathy,  the surrounding parts participating with the point of irrita-
tion ; and  in proportion to the health of the surrounding parts, and
constitution, this sympathy is less.
  The act of inflammation seems to consist in an increased action
of the vessels ; mostly, if not altogether of the extreme vessels ; for
wherever  inflammation appears, it  may  be confined to a point in
which none but the smallest vessels can exist.
  The first act of the vessels when  the stimulus  which excites in-
flammation is applied, Mr. Hunter supposes to be precisely similar
to a blush; and to consist in a simple distention or increased dia-
meter beyond their natural size ; such as we see take place on the
application of a gentle  friction, or of gently stimulating medicines,
to the skin ;  and  the consequence of which is a warm  glow, when
limited to  the  degree we  are now supposing; but which, if carried
farther, would be followed with excoriation, suppuration, and ulcer-
ation.
  The inflamed vessels, being thus enlarged and irritated, begin to
separate from the blood they contain some portion of its coagulating
lymph, together with some serum, and red globules ; and to throw
these materials out on the internal  surface  of the part  inflamed;
probably  through the  exhalants, or, perhaps, jjybrough new  ves-
sels  which may be now forming around them; whence the sides of
the cellular membrane, which receive the effusion, become cover-
ed with it, unite with the opposite sides with which they are in con-
tact, and thus form the first foundation of adhesions.  The increased
bulk of an inflamed part is produced chiefly by  this effusion; and
the increased redness, partly by the larger quantity of blood con-
tinued  in the distended old vessels,  and partly by the production of
new vessels formed out of the coagulable lymph thus extravasated ;
and which, by innumerable inosculations and adhesions, interpose  a
check to suppuration, which would  otherwise most probably  take
place.
  Inflammation, therefore,  consists in an increased impetus and ac-
cumulation of  blood in the  vessels  affected, accompanied with  a
proportionate  swelling and sense of heat.  The physiologists  have
pretty  generally  concurred in ascribing this accumulation of blood
to an obstruction of some  kind or other; but they have differed  upon
its nature  and origin; and have not been able to determine whether
it be dependent upon the crasis of the blood itself, or the resistance
of the  \ essels that contain it.
  Generally speaking, however,  it has by all the schools of medi-
• 
CL. IH.-OR. II.]      SANGUINEOUS FUNCTION.
155
 cine been  ascribed to whatever has been supposed to be the proxi-
 mate cause of fever :  and hence the humoral pathologists attributed
 it to a lentor or viscidity of the circulating fluid ; and the corpuscu-
 lar, to an error loci,  concerning both of  which we  have already
 treated ; the cause of obstruction in the  view of either  hypothe-
 sis, being  seated  in  the nature or misdirection  of the  constituent
 parts of the blood itself: while Dr. Cullen refers it to the same kind
 of spasm  which he regarded as the proximate cause of fever ;  and
 hence derived the obstruction from a constrictive  resistance in the
 vessels of the part affected : which, he farther supposes, forms but a
 mere link  in the tensive chain of a phlogistic diathesis, which more
 or less  runs  through the  entire habit at the time  of inflammation,
 and constitutes the predisposition to its rise and progress.
   " That a spasm," says he, " of the extreme vessels takes place in
 inflammation, is presumed  from  what is at the same time the state
 of the  whole arterial system.  In all  considerable  inflammations,
 though arising in one part only, an affection is communicated to the
 whole system ; in consequence of which an inflammation is readily
 produced in other parts besides that first  affected.  This general
 affection is well  known to  physicians  under the name  of diathesis
 phlogistica.  It most commonly appears in persons of the most rigid
 fibres; is often manifestly induced by the tonic or astringent power
 of cold ; increased by all tonic and stimulant powers applied to the
 body; always attended by hardness of the pulse; and most effectual-
 ly taken off by the relaxing power of blood-letting.  From  these
 circumstances it is probable that the diathesis phlogistica consists in
 an increased tone or contractibility, and,  perhaps,  contraction of
 the muscular fibres of the whole arterial system."*
   To  the  first two of these hypotheses  the same  objections apply
 that  we have already seen apply to them as causes of fever.   That
 an error loci occasionally takes  place, or, in other words, an  en-
 trance of red or other particles of blood into minute vessels  to which
 they  do not naturally  belong, is unquestionable ;  but then this is
 rather a secondary than a primary link in the chain  of inflammation,
 and consequently an effect rather than a cause, as we shall presently
 have to notice more at large.
   Yet the  hypothesis of Dr. Cullen does not seem to be  more satis-
 factory, and is especially open to the two following  objections,  to
 say nothing of various minor difficulties with which it is  attended.
   It supposes, in the first place, as a general rule, that inflammations
 of every kind,  however  minute and circumscribed, are dependant
 upon a particular  habit  of  body at the  time, distinguished by the
 name of a phlogistic diathesis.  But we see  inflammations occurring
 in habits of every  kind,  and varying in many of their features  ac-
 cording to  the variety of the habit;  and we see them also arise in
individuals who have no such phlogistic habit or diathesis as is here
referred to.  And  we often, moreover,  see examples of this very
* Pract. of Phys. Vol. iv. Sect, ccxlvii. 
156
HiEMATlCA.
[CL. IIL-OR. II.
diathesis operating upon individuals for years, without  producing
any such effect as inflammation in particular parts.  And we cannot,
therefore,  regard  such a diathesis as a proximate cause  of inflam-
mation in general, though it may often be so of a particular kind of
inflammation.   Dr. Cullen, indeed, was aware of this difficulty, and
even  admits it. " Such a state  of the system,"  says  he,  " seems
often  to arise and  subsist for some time  without the  apparent in-
flammation of any particular part;  but such a state of the system
renders it likely that a spasm may, at  the same time, readily arise in
any of the extreme vessels,  and a particular inflammation be there
produced.  It does, however,  appear  also, that the general diathesis
frequently arises from inflammation begun in a particular part."*
  Now this is not only to admit  the difficulty but to fall  prostrate be-
fore it.  It  is to  admit what at once settles the  entire question.
The cause  and  the effect are  made to change places : and the phlo-
gistic diathesis  is as broadly stated to originate  from inflammation
in a particular part, as  inflammation in a  particular part is stated to
originate in the phlogistic diathesis.
  But, secondly,  this hypothesis seems  not only to be chargeable
with incongruity, but to be directly at variance  with the ordinary
train of phaenomena by which inflammation is  accompanied.  That
the habit here alluded  to  under the  name  of diathesis phlogistica
exists, and that  very frequently,  is not to be  questioned; and  Dr.
Cullen has  very lucidly described what  is  ordinarily  meant by it.
" It seems probable," says he, " that the  diathesis phlogistica con-
sists in an increased tone or contractility, and perhaps in  an increas-
ed contraction of the muscular fibres of the  whole arterial system ;"
—" it appears most commonly in persons of the  most rigid  fibres."
But I believe it will be found by every one who investigates the
subject, that so far from  this being the habit  of  body  in which
inflammation is most frequently to be met with,  it is that in which
it occurs more  rarely than in many others.  That it occurs in it at
times is unquestionable, for inflammation under some form or other
occurs in  habits  of every kind: but if we look  for  specimens of
larger or smaller inflammation, of deep-seated  or superficial, nay,
even  of suppurative or ulcerative, we  shall meet with  them,  if  I
mistake not, far more generally in constitutions marked  by  mobile
and irritable than by firm and rigid  fibres;  in habits characterized
by  atonic rather than by entonic  action.   It is not till the constitu-
tion has been broken down, and the liver rendered  feeble  and tor-
pid by the  influence of a tropical sun,  that  hepatitis makes its ap-
pearance in its ordinary course of attack; phthisis occurs in relaxed
and delicate, and not in hardy and robust frames ; psoas abscess, pe-
ritoneal  inflammation, struma, and those  vast  formations of pus
which are  sometimes found in parabysmic tumours  or physconics,
for the most part  follow the  same track; while  the best, if not the
only remedy for the innumerable host of erythematic inflammations,
* Loc. citat. 
CL. III.-OR. II.]        SANGUINEOUS  FUNCTION.             157'

whether erysipelatous, gangrenous, or vesicular, pernio or intertri-
go, is to raise the part or the constitution  to  that scale of vigour
the reduction of which is well known to form a common predispo-
sition to all of them.  That there may exist such a condition of bo-
dy as an inflammatory diathesis, or a predisposition to inflammatory
action of some kind or other, according to the  idiosyncrasy or esta-
blished  habit,  or some  controlling accident, is unquestionable ; but
such a diathesis cannot be  made synonymous with the phlogistic
diathesis as described by Dr. Cullen, unless there be  but one kind
of inflammation, and that such an inflammation as has a natural and
necessary relation to the entony and rigidity of fibre which is here
presupposed.
   The  little that we know upon the subject may, perhaps, be com-
prized in a few words :  The standard of firm health is the best guard
against  inflammations of every kind, or the state in which a man  is
least susceptive of them;  and a deviation in either direction, whe-
ther towards a habit of entony or of atony, capacities him for breeding
them.   But it does  not capacify him equally :  for in  the  latter case
they are produced far*more easily and generally than in the former.
In fibrous entony, obstruction appears to  take place,  and inflamma-
tion to  follow, from an increased tendency to constriction and rigi-
dity in  the muscular tunic of the arteries generally, and an actual
constriction in those of the part affected; in consequence of which
the diameter of the tube is diminished, and the blood, though urged
by a stronger impetus from behind,  works onward with less free-
dom than usual.  In fibrous atony, obstruction  takes place from the
relaxed and yielding state of the vessels  which  admit  grosser cor-
puscles of the blood than what naturally  belong to  them, and thus
become accessary to the error loci of the Boerhaavian  school.  But
a mere  error loci is not sufficient for  inflammation ;  since the erra-
tic corpuscles are readily  forced back, or pass diagonally into larger
vessels  from the numerous anastomoses that prevail  in the arterial
system.   Of this we  have  a pertinent example in the red  suffusion
which frequently takes  place in the tunica albuginea of the eye,
which is often an effect of weakness  alone, is unaccompanied with
heat or pain, and consequently with inflammation, and perhaps pass-
es off by the next day   In addition, therefore, to the  relaxed state
of fibres and the error loci before us, there must  be something  of
that irritability which is so  frequently an  attendant upon relaxed
and mobile  organs, and which  produces  spasmodic and  contractile
action in a far higher degree, though, perhaps,  in irregular fluxes
and refluxes, than any habitual firmness or rigidity of  fibre does  at
any time.
..^ And as in weak parts or habits a peculiar susceptibility of irrita-
tion seems to be a necessary adjunct in the production  of inflamma-
tion, it  is possible that it may be equally necessary in the  opposite
state of excessive firmness and rigidity of fibre ;  since  this also,  as
just observed, will,  at times, continue for years without giving rise
to any inflammation whatever, and seems equally to  demand  an ex^ 
158
HyEMATICA.
[CL. HI.-OR. H.
citing accessary.   And hence the real inflammatory or phlogistic dia-
thesis, constituting however a remote, more properly than a proxi-
mate cause, is perhaps to be  found  in  increased  irritability  ot  the
living fibre rather than an increased rigidity and vigour.
   Concerning then  the proximate  cause  of inflammation, there is
yet much to be unravelled.   Of its remote causes and  a  tew of its
laws, we are in some degree better informed.  The remote causes
may be contemplated under the three following divisions :
   First, some accidental violence applied to a part,  so  as to  make
a wound or bruise from which it cannot recover except by the pro-
cess of inflammation, or which, at least, has a  natural  tendency to
excite such a process.
   Secondly, some irritation which does not  destroy  the texture of
the part, but merely its natural action; as pressure, heat,  cold, blis-
ters, pungent applications, and often fevers of every  kind.
   Thirdly, a particular disposition  to  inflammation, founded, per-
haps, as we  have just observed, in an irritability in the  morbid part
itself, and which we often behold in constitutions of the  best state
of health; affording  proof that the  general %abit  is not, in such
cases, concerned in  the morbid change.   Inflammations  from  any
of these causes will, however, partake of the character of the con-
stitution ; and hence proceed  kindly or unkindly, according  as  the
constitution is in a diseased or a healthy condition.   Yet the gene-
ral principle of inflammation is  the same in all; for we can only
contemplate it as a remedial process, an instinctive effort, or exer-
tion of the vis medicatrix naturae, to bring about a re-instatement of
the parts nearly to their natural functions.
   Yet, though inflammation is uniformly the same in its principle,
it  often differs widely in its mode of action, and consequently in its
result;  for as it has  a tendency to partake of the character of the
constitution, and especially where it is extensive, according as  the
constitution is healthy or unhealthy, so will be  the nature of the in-
flammation and the diversity of its  progress.
   Healthy inflammation consists probably of one kind alone,  and is
no farther divisible than into different stages of a restorative action,
the effect of an instinctive stimulus rather than of morbid irritation.
Unhealthy inflammation consists  of many species,  for numberless
are the diseases that effect the health of the constitution; and con-
sequently that may influence the character of the inflammation, by
superadding peculiarities or specific actions of its own:  though it is
often affected also by the particular condition of the part  in  which
the inflammation takes place.  And hence it is no uncommon thing
for particular parts to run into  particular inflammations with  the
character of which the constitution has little concern; such as those
that are  occasionally found on the skin, particularly the  erysipela-
tous, as they are commonly  but  not quite  correctly denominated,
and which we shall  presently have to describe under  the name of
erysipelatous erythema.
   Simple or healthy inflammation  is capable  of producing three 
CI.. III.—OR. II.]     SANGUINEOUS FUNCTION.               159

different effects, which, where the whole take place  healthily, fol-
low in regular order, and constitute so many stages.   These are
adhesions  of the parts inflamed,  suppuration, and  ulceration ; to
which three, different effects Mr. Hunter has given the names of the
adhesive,  the suppurative, and the ulcerative inflammation.
   There is good reason for this division into different heads; for
although,  where the whole take place healthily, they follow in the
order  now enumerated, yet the  whole do  not always take place
either healthily or unhealthily ;  nor is the order thus enumerated
in every instance attended to.   For pus, as  we shall have occasion
to observe more largely hereafter, is often  produced when there is
no adhesive inflammation; and  ulceration, when there  is neither
adhesion  nor  suppuration: while  occasionally the suppurative and
adhesive  inflammations take place  simultaneously;  the former be-
in°- hurried on before  the other has completed its own bounds, as is
often the  case  in peritoneal inflammation after child-birth.  The
degree of violence  also  with which the inflammation commences,
produces  a considerable influence  upon these points ; and the nature
of the parts themselves still more.
   With the nature of  the parts  that constitute the chief fields  of in-
flammation, it is of high importance that we  should make ourselves
deeply acquainted from the first, that we may be able to determine
concerning the  particular course the  inflammation is likely to run,
 and regulate our treatment accordingly.  And it is  of still  farther
importance that this subject should be  attended  to  on the present
occasion, because it is on this distinction of parts, producing a natu-
ral tendency to distinct inflammations, that the genera of the  order
before us are principally constructed.
   The whole of the observations  of Mr. Hunter upon this interest-
ing point are entitled  to the  most patient  study, and cannot be too
closely committed to memory.   In the present place I can only re-
 mark, that, in treating of inflammation, he  divides the body into
 two parts : firstly, the circumscribed  cavities, organs, and cellular
 membrane which connects them ;  and, secondly, the outlets' of the
 body, commonly called  mucous  membranes, as  the ducts  of the
 glands, alimentary  canal, and  similar  organsjfcle distributes in-
 flammatory affections, as  1 have just observed^nto three sorts, ad-
 hesive, suppurative, and ulcerative.  Adhesive inflammation belongs
 chiefly to the former of the above two parts of the body, where they
 are deeply seated;  and appears intended to take  place  for the pur-
 pose of preventing  suppuration.   It applies, therefore, peculiarly
 to that genus of the present order which we shall denominate em-
 fresma, and which will embrace the visceral organs, allowing for
 one  or two exceptions that are occasionally  interposed.   Suppura-
 tive inflammation   belongs chiefly to  the same  division of parts
 placed near the surface ; and consequently applies to the two genera
 here denominated phlegmone and phyma, embracing small cutaneous
 abscesses of various kinds.  The  ulcerative inflammation belongs
 chiefly to the  second  order of parts, as the mucous membranes and 
 J 60                     H.EMATICA.            [cL.lH.-OR.il-

 outlets; and hence applies principally  to  the  genus  erythema, or
 inflammatory blush ; often, but improperly, called erysipelas, which
is an exanthem or eruptive fever, accompanied with erythema.  It
 also applies to  that peculiar inflammation which  characterizes the
whitloe, and will be found in the present arrangement  under the
genus phlysis.   Deep-seated suppurative inflammations and absces-
ses cannot well be placed in either of the genera we have thus tar
noticed; and have a claim to be  considered by  themselves^  lhey
are hence included in the genus apostema,  with which  the  order
will be found to open.
  Inflammation, therefore, is influenced by the nature of  the part
in which it takes place.  It is also, as  we have  already observed,
equally  influenced by  the nature of the constitution itself; and,
thirdly,  it is influenced  by the nature  of the remote cause.  And we
may add, that, where the inflammation is regulated by the  constitu-
tion, and the constitution itself is healthy, specific irritants will not
change the nature of the inflammation, but only determine  its situa-
tion, extent, duration, or some other peculiar property.  But where
the constitution is unhealthy,  or  predisposed to any  particular mor-
bid action, as that of erysipelas, putrid fever, or  plague, (for some
individuals receive even the plague much more readily than others,)
as soon as the  specific virus is communicated,  the  disease will de-
generate into a mixture of both, and discover its double  source ; it
will give proof that a specific inflammation has  been set down upon
a constitution of a peculiar kind, and will partake of the nature of
both.   In consequence  of which, the specific properties will  by no
 means be so distinct or  well formed as if  they  were to appear in a
sound and untainted constitution.
  Thus, if the  constitution have a susceptibility to become putrid,
 and the small-pox attack it,  the inflammation  will  be that of the
 small-pox combined with the  constitutional tendency to  putrescen-
 cy; which will so far affect the  action of the small-pox as to inter-
 fere with the specific difference of its inflammation.   In consequence
 of whieh, the pustules  will spread, but not suppurate, and assume a
 livid hue, and perhaps prove fatal; while if another person posses-
 sing an  uncorrupt jfcd, so to  speak, unbiassed constitution,  be in-
 oculated even  witrTthis mixed  virus, the variolous principle will
 separate itself from the principle with which it is combined, im-
 prove with the improvement of the new soil,  and  yield a crop of
 genuine and unadulterated pustules.
   In like manner vaccination is, generally speaking, a specific pre-
 servation  against the small-pox.  But it sometimes  happens that it
 is not so; and that the  small-pox is caught and makes its appearance
 many years after vaccination has  been resorted to,' and  performed
 with  all possible circumspection.  And it generally happens in such
 cases, though not  always, that a mixed or hybrid disease, a sort of
 degenerate small-pox of a milder character than the true, is hereby
 produced.
   The  remarks just laid down will furnish us with a clear  and suffi- 
CL. III.-OR. II.]
SANGUINEOUS FUNCTION.
161
cient clue to these  singular  and interesting  facts.  Some  persons
have a peculiar predisposition to  small-pox, which is  by no means
easily eradicated, and far less so than in others.  Vaccination, which
permanently counteracts the predisposition among mankind in gene-
ral,  does not permanently  counteract it here.  It introduces a new
but less rooted diathesis, and  the  former is rather  suppressed than
extirpated.   In  process of time  the  predisposition revives, re-ac-
quires its anterior influence, and the moment it comes in contact with
variolous  contagion,  subjects the system to  smail-pox.  But while
the variolous diathesis is  thu- again become  predominant, the vac-
cine diathesis has not altogether lost its hold;  and the  disease, as in
the preceding cases, is a mixed product of both causes in co-operation,
or rather in antagonism.  It is small-pox raised upon a constitution not
yet totally liberated from the influence of vaccination ; I say,  " not
yet totally liberated," because we occasionally meet with instances
in which  the constitution, little  open to the impression of  the vac-
cine disease,  even when first communicated, becomes in time lib-
erated  from  its influence altogether, and  receives  the small-pox,
after vaccination, as freely as if  it had never been  vaccinated, and
with a  violence that  proves fatal in a  few days.
   It is  a  wise and beneficent law of  providence, and  affords an in-
controvertible proof of the  existence  of  an instinctive remedial
power, that inflammation, wherever seated, is always more violent
 on the  side of the inflamed point nearest the surface, and  shows a
 constant tendency to work its way externally rather than internally.
 This law applies equally to the thorax, to the abdomen, and to parts
 which  lie close  to the different  outlets of  the  body.  Thus, if an
inflammation attack the peritoneum covering an intestine,  and ad-
 hesions are  hereby  produced between the  two, the  inflammatory
 action  works upwards through   the  thick  walls of the abdominal
 muscles,  while the proper coats of the intestines in most instances
 remain sound.   This, indeed, is not always  the case ;  for the in-
 flammation may be so violent as to pass in both directions with great
 rapidity, or some accidental circumstance  may guide it inwardly;
 but it is  so common as to form a general  ruie.  We see the same
 thing in the  obstruction of the natural passage of the  tears produc-
 ing a fistula  lachrymaiis; for here the  ulceration  points externally
 to the  inner  angle of the eye, while  the inside  of the nose defends
 itself by  becoming thicker;  so much so, in many cases, as  to block
 up the cavity of the nostril, a*nd produce irfosculations with ihe sep-
 tum ;  which has been an occasional cause of failure in the usual
 operation for this disease.*   We even find that if an abscess form
 in a frontal  sinus from an obstruction  in its duct, the  matter will
 rather work its  way externally  through the  frontal bone  than des-
 cend into the nose.   In like  manner, if an inflammation attack the
 cellular  membrance on the  outside  of the  rectum near the  anus,
     * See Hunter on Blood, Inflammation, Lc. Fart 11. Chap. ix.
VOL.  II.             21 
162
HvEMATICA.
[CL. III.-OR. II.
although the latter  be in  contact with  the  inflamed part,  the in-
flammation will extend to the skin of the buttock, while the gut it-
self is often but little affected.
  For  the  same reason we behold eruptive fevers  conducting the
specific poisons  which excite  them, as small-pox,  measles, rosalia,
or scarlet fever, and even the plague itself, to  the surface of the
body, rather than throwing them on parts that are deep-seated and
vital.  The cancer is said to form an exception;  but even here the
progress of the disease towards the surface is  quicker than its pro-
gress towards the centre :  while syphilis exhibits  something of a
similar disposition though not in an equal degree.
  It appears then that simple or healthy inflammation is a remedial
process for restoring a  part to soundness when affected by a  morbid
impression  that has a tendency to injure or destroy it:  and that the
first stage of this process consists in the effusion of a coagulable lymph,
which binds the  weakened  organization into a closer bond of union,
creates new vessels,  and  consequently introduces new life.  If this
effort do not succeed, and  the morbid action  still continues its pro-
grees, the affected part dies to a certain extent;  but the coagulable
lymph  which has been  thrown out,  and introduced new  vascularity
around it, still sets a boundary to the destructive career, and prevents
it from spreading into the neighbourhood, or at least  from spreading
as far as it  otherwise  would do.  When, however, a part is thus
killed or destroyed, it becomes a substance foreign to the body, and
must be removed, and  have its place supplied by a formation of
new living matter.  The  process of suppuration,  which we shall
explain under the genus afostema, prepares equally for the removal
of the dead matter and the formation of  that which is to fill up its
post. This, however, is the progress of healthy inflammation alone ;
for, as already observed,  in unhealthy inflammation,  the morbid ac-
tion will often run on to the ulcerative process or last stage at once ;
or the  adhesive, or the  suppurative  may  intermix with  it; or all
may imperfectly take place together.
   In attempting the  cure of inflammation, our first endeavour should
be  to obtain what has been called a  resolution  of  the general en-
largement;  or, in other words, a restoration of the part to its state
of former  health,  without the  necessity of  its  going through  the
entire  range of the  inflammatory  process.  And in doing this  we
are to be guided by  the principle of being able  to make a new  im-
pression upon the part, and to  oppose a healthy or  remedial to an
unhealthy and mischievous action.   The nature of the cause must
hence be sedulously inquired into, for till this is  ascertained and re-
moved, it will be in vain to expect that resolution  can take place,
and where we can  speedily accomplish such removal,  resolution
will often follow spontaneously; for the animal  economy having  a
disposition in itself  to discontinue  diseased action, such action will
readily subside upon a  disappearance of the cause that maintains it.
And hence  by taking off the venereal action by the  use of mercury
in the case of a bubo,  the  inflammation  will gradually  cease, pro- 
CL. 1II.-0R. H.]
SANGUINEOUS FUNCTION.
163
vided no other morbid  action has already arisen and  united itself
with the syphilitic.
  Resolution,  however, is  not  always to be attempted; for there
are many cases in which the attempt would be in vain,  and possibly
a few in which it would be improper.  It is not to be attempted in
accidents where  there  is  a considerable exposure of the  injured
part; and still less in accidents where the  part has been killed  by
their violence : for in these, suppuration is the first natural step to
a cure,  and we cannot prevent it if we would.
  Where inflammation  arises  from a morbid predisposition  in the
constitution, and belongs to the description  which has been called
critical, there is some doubt, and much demand for circumspection:
and in this case resolution is called repulsion.  If the inflammation
be really a concentration of the constitutional complaint, which,  by
being driven from the part fixed  upon, may be again diffused over
the entire frame, and in waiting to fasten on some other part, it will
often be better to encourage its stay.  But the determination even
in this case must be subject to the two following conditions :  first,
that the inflammation so concentrated will readily admit of a cure ;
and, next, that the part on  which  it fixes is not of vital importance;
for otherwise the remedy ma}' prove worse than the disease.
   When resolution is determined  upon, independently of removing
the  cause of the inflammation, we may advantageously follow  up
its effects by all  the common  modes employed for this  purpose, ac-
cording to the nature of the particular case.  The undue degree of
action may be diminished by bleeding and purging ; the distension  by
local applications that tend to contract the diameter of the vessels,
as cold, and metallic or other astringents;  and  if along with the
distension there  should  be  great  pain, narcotics  and relaxants will
generally be found useful auxiliaries.   To these in the present day
are often added nausea and vomitmg, the former of which operates
by lowering the  action  of  the  vessels;  Ihe latter by giving a ten-
dency to a new action.  The nature  of the case must determine our
choice.
                      GENUS  I.

                       APOSTEMA.

                          sa^osteme.

LARGE, SUPPURATIVE INFLAMMATION IN A DEEP SEATED ORGAN ; PUS COPIOUS:
                         AND CONFINED.

The term apostema is Greek, from xf tempi, " discedo,'1 " abscedo,"
—whence the Latins employed abscessus, to express the same general 
164
llttMATICA.
[CL. IH.-OR. II.
 idea.  Yet they did not, strictly speaking, apply either abscessus or
 apostema to every suppurative  inflammation, but only to those that
 were deep-seated, and  of considerable extent; chiefly indeed to
 collections of pus consequent upon fevers, or some previous disorder
 of particular parts, especially abdominal diseases.  This limitation
 is accurately drawn by Celsus  immediately after his  description of
 struma, furimculus. and  phyma.  " Sed  cum omnes hi nihil nisi
 minuti abscessus tint, generate nomen trahit latius vitium  ad suppura-
 tionem spectans.   Idque  fere fit aut post febres, aut post  ordoles
 partis  alicujus,  maximeque eos qui  ventrem infestarunt."   The
 term abscess however, which was colloquially used  in a loose  sense
 in the time of Celsus, is  used so much  more loosely in our own day,
 that it is impossible to recal it to its precise and original  meaning.
 Yet apostema has not been thus generalized; and it is here, there-
 fore, laid hold of and restrained to the  signification expressed in the
generic definition ; after the authority, indeed, of Sauvages, who has
employed it with the same  limitation.
   the genus apostema in the arrangement before us will be found
to include five species : the first of which is common to  most fleshy
parts, and possesses a common character ; while the remaining four
are distinguished by some  peculiarity  of character, produced by a
peculiarity of situation:

 1. apostema  commune.         common aposteme.
2. ------<—  psoaticum.        psoas abscess.
3. --------  hepatis.          abscess of  the liver.
4.--------empyema.         lodgment of  matter in the CHEST.
 5.-------: VOMICA.          VOMICA.
                         SPECIES  I.

               APOSTEMA  COMMUNE.

                    Common ^yostrmr.

INFLAMMATION COMMON  TO  THE FLESHY PARTS : PAIN OBTUSE : TUMOUR
  SPREADING EXTERNALLY : TENDER TO THE TOUCH : PUS LAUDABLE : READILY
  INCREASING WHEN OPENED.

In whatever part an aposteme is seated, it will sometimes spread to
a wonderful  extent, and be loaded with a prodigious  weight of pus
M. Balme gives us an account of an abscess that extended  through
the  whole  parietes of the  chest  and abdomen on one side  and
reached from the scapula to  the thigh ;* and Hildanus was present
* Journal de Medicine, &c. Tom. xvn. 
GE. I.-SP. I.]          SANGUINEOUS FUNCTION.            165

when, upon opening a patient after death, twelve pints of pus were
found effused  from a  visceral  aposteme into the cavity of the
abdomen.*                                                  .
  In all such cases the first stage of inflammation, that ot adhesion,
must have been overshot in the violence of the action, or from some
other cause,  and the suppurative  and  ulcerative have commenced
simultaneously from the first.  For otherwise the coagulable, or as
Mr. Hunter  prefers to  call it, the  coagulating lymph  thrown forth,
as has been already explained,  into the cellular membrane in the
earliest stage  of the inflammation, would have formed a boundary
wall by the production of new vessels and reticulations, much nearer
to the salient  point of the  inflammatory action, and confined the
secretion of pus to  a much narrower limit.
   The secretion of coagulable  lymph, and the reticulate adhesion
and formation of new vessels which issue from it, is indeed designed,
as  has been explained  already,  to prevent  the  necessity of the
suppurative and ulcerative stages  of inflammation; and the natural
cure of the  adhesive stage is by resolution.
   When, therefore, an aposteme takes place in a healthy frame, or,
 in other words, when the inflammation passes into the two ensuing
 stages of the suppurative and ulcerative, and pus is formed, and a
 cavity scooped out for its  reception,  we are  to take  it for granted
 that the instinctive and remedial power of nature is incapable of
 producing a cure  by  the first  intention;  that  some dead  part or
 extrinsic substance is required to be  removed, and that the two
 ensuing stages of inflammation are had recourse to for this purpose.
   In the formation, then, of an aposteme in a healthy constitution,
 we are to suppose that some part of the  organ in which inflamma-
 tion occurs, as for  example, a piece of the muscle of an  arm or a
 leg, is become dead,  and  an incumbrance to the living  parts that
 surround it, instead of assisting in their office.  In effecting, there-
 fore, the important object of a cure, it is obvious that two distinct
 actions  are necessary;  the dead part must be carried off, and its
 part must be  filled up by a substitute  of new  matter  possessing the
 precise properties of the  old.   And in the process which takes
 place to accomplish  these  two  purposes, we meet with another
 clear and striking instance of that  wonderful instinctive power which
 pervades  every portion, both of  the  animal and  the  vegetable
 world,  and which is perpetually stimulating them to a repair of
  whatever evils  they may encounter, by the  most skilful  and defi-
 nite methods.
    In order to comply with this double demand of carrying off the
 dead matter,  and of providing a substitute  of new, the absorbent
  and the secernent vessels in the  living substance that immediately
 surrounds that which requires  to be removed, commence equally,
 and nearly at the same  time,  a  new mode  and  a new degree of
 action.  A boundary  line  is first instinctively drawn between the
* Cent. n.  Obs. 57. 
166
HjEMATICA.
[CL. III.-OR. II.
dead  and  useless,  and the living  and  active parts; and the latter
retract and  separate  themselves from  the former, as though they
had been skilfully divided by a knife.  This process being com-
pleted, the mouths of the surrounding absorbent vessels set to work
with new  and increased power, and imbibe and carry off whatever
the material may be of which the dead part  consists, whether tat,
muscle, ligament, cartilage, or bone;  the Whole is equally sucked
up  and taken away,  and  a hollow  is  produced  where the  dead
substance  existed.
  While this is proceeding, the mouths of the corresponding secer-
nent vessels from  the first, and  perhaps somewhat  antecedently,
commence a similar increase and newness of action ;  and, instead of
the usual fluid, pour forth into  the hollow a soft, bland, creamy, and
inodorous  material, which progressively fills up the cavity, presses
gradually against the superincumbent skin, in the gentlest manner
possible distends and attenuates it, and at length bursts it, and exposes
the interior to  the  operation of the  gases of the atmosphere.
From this  period the  process of incarnation  commences : granula-
tions of new living  matter pullulate  on  every side, assimilating
themselves to the nature of the different substances that are lost, till
the hollow is sufficiently filled up, and the organization  completely
regenerated.
  On the bursting of an abscess externally, we occasionally find that
a portion  of the  dead matter still remains,  which is,  afterwards,
gradually sloughed away, or is thrown off by a separation at its base.
This is particularly the case in furuncles or boils;  and still more
strikingly  so in  large abscesses that include bones or the tendinous
parts of muscles which are more difficult of absorption, though even
these are sometimes absorbed, and completely carried off.
  The attenuation of the superincumbent integuments of an abscess
appears to be produced by the stimulus of distension occasioned by
the pressure of the accumulating pus.   And it  is to the same stimulus
that Mr. Hunter resolves the absorption  of the dead  matter  itself,
conceiving that for this purpose the secretion of the pus commences
somewhat earlier than the absorbent  process.
  The formation of pus, and consequently the existence of an apos-
teme, is evidenced by a cessation  of  the  pain of  distension, which
gives way to a throbbing pain, synchronous with the dilation of the
arteries ; and by irregular shiverings, and sometimes rigor.   After
a few days a weight is felt  in the part,  the  throbbing pain itself
subsides,  the tumour becomes soft, and,  if it  point  sufficiently
towards the surface, fluctuates  to the  touch.
  There is some doubt to whom we are indebted for the first insight
into this wonderful process; for it was  taught at the same time, or
nearly so, on the continent by De  Haen, Plenciz, and Schreder, and
in our own country by Hewson,  Hunter, Home, Cruikshank,  and
Professor  Morgan: but upon  the  whole, Mr. Hewson  appears to
have taken the lead, and the  rest to  have followed closely in his
steps.  Antecedently to which period, pus, instead of being a pecu- 
GE. I.-SP. I.]         SANGUINEOUS FUNCTION.              167

liar secretion, was supposed to consist in a dissolution of the blood-
vessels, nerves, muscles, and other solids, in the ordinary exhaling
fluid when augmented by effusion ; or in a conversion of the serum,
thrown  forth on the occasion, into the new  matter,  by a  change
effected in  its gluten during its  state  of stagnation :  the  first  of
which hypotheses was that of Boerhaave,* Platner,t and almost all
who practised antecedently to their time ; and  the  second  that  of
M. Gaber,J and Sir John Pringle.§
  These conjectures were ingenious, but they were nothing more;
and their errors are sufficiently pointed  out in the  ' Experimental
Inquiries' of  Mr.  Hewsou, to whom physiology, and especially the
science of morbid anatomy, is almost  as  much  indebted as to any
person whatever.   He travelled with a comprehensive mind, and a
zealous and indefatigable step, in what  was at  that time new and
untried ground;  and  though  he  was mistaken  in a few points, he
correctly explored much, and, by the  course he laid down, indicated
to his successors the truest methods both of confirming his facts and
correcting his misconceptions.
   He proved decidedly that pus is a peculiar secretion, and that it
is often, indeed,  secreted where there is no abscess or breach  of
surface : and he ingeniously accounted for  its  production by suppos-
ing it to be formed out of the coagulable lymph by a new power
given to the secernent  vessels in consequence of the  inflammatory
action.  " And if pus,"  says  he, " in these cases, is  produced
merely by a secretion, so likewise it  would seem probable,  that
even in abscesses, where  there is a loss of substance, it is not the
melting-down of  the solids that gives rise  to  the pus,  but  the pus
being secreted into the  cellular  membrane from its pressure, and
from other causes, deadens the solids, and then  dissolves\\ them."
   This idea  of the solids  contained in an abscess being deadened
and  dissolved by the  pus which surrounds them,  in the ordinary
sense of the expression, (for in one sense, as  will appear hereafter,
they may be said to be dissolved,) was one of the erroneous opinions
of Mr  Hewson to which I have just  alluded; and originated frpm
too close an adherence to the earlier, and still more mistaken hypo-
theses we have just noticed.
   And  hence, with all  his  ingenuity,  Mr.  Hewson advanced not
 much more than halfway in explaining the entire economy of sup-
 purative  inflammation.   It remained  for the  exploring  eye and
commanding genius of Mr. Hunter to penetrate  through a conside-
 rable portion of the  remaining half of  this curious  process, and to
prove that the solid parts contaiued in  the are- of an abscess, in-
* Aphor. 387.
t Instit. Chirurg. Sect. liv.
X Acta Taurinensia, Vol. n.
i Treat, on the Diseases ot the Army, app.
|l Experimental Inquiries, Part. n. p. 118. 
168
HJEMATICA.
[CL. IH.-OR. 11.
stead of being deadened  by the  pressure  .of the surrounding  pus,
are dead before-hand, destroyed indeed by the violence of the ac-
cident, or of the inflammation;  and that, instead of being merely
dissolved in the circumambient pus, they are absorbed and carried
off by a new and increased action of the circumambient absorbents ;
thus showing that even ulceration itself,  when of a healthy kind,
is  only another link in the restorative chain of nature  made use  of
on this occasion.
   The greater part of this  nice fabrication is rendered so  clear in
Mr. Hunter's admirable work on inflammation, and his arguments
and his facts  have been  so fully confirmed,  and so  abundantly ex-
emplified by later physiologists, and particularly by Mr. Cruikshank
in  his valuable treatise on the absorbents, as to remove every doubt
upon the subject in the minds of the great body of the  profession.
And it is hence not a little surprising, that  Dr. Cullen's Practice of
Physic should be still printed and circulated,  and more than  this,
be still employed as a text book (as I am told it is,) in many of the
most celebrated schools of the present day, with the old,  mistaken,
and exploded hypothesis of the formation of pus out of secreted se-
rum, advanced as a true and genuine doctrine,* without the slight-
est hint of  any newer or more  satisfactory explanation of the sub-
ject.
   It is  still  more surprising,  that the  same  antiquated  doctrine
should be  taught in  the  latest editions of Mr. B. Bell's  valuable
treatise on ulcers :j and most of all, (to the present author, at least,
most of all,) that  his friend  Dr. Parr, with all the light of  his con-
temporaries before him, should have offered  it as his  own opinion,
in  his elaborate and upon  the whole  very excellent  Medical  Dic-
tionary ; in which he tells us, after M. Gaber, that the pus of an ab-
scess " consists of the substance  of the vessels, and of the cellular mem-
brane dissolved in the serum."
   That pus, instead of being a mere  solution of dead animal  mat-
ter, is a distinct and peculiar secretion, is now known  to most prac-
titioners from  personal observation ; who must have witnessed it
repeatedly in situations in which  there has been no ulceration or
breach  of  structure,  and consequently where there  could be  no
dead animal matter to dissolve.
   It was noticed  in this form by De Haen so far  back as  the mid-
dle of last  century;  and  was  pointed out by Mr. Hewson as fre-
quently found, on dissections, on the  surface of the  pleura, the pe-
ritoneum, the  pericardium,  in a perfectly genuine  state.   A  very
decided case, to which both Dr. Hunter and  Mr.  J.  Hunter were
witnesses, was  published by Mr. Samuel Sharp about the same time
that De Haen first brought the subject before the  public.    No-
thing is more common  or  more  copious than  the  secretion of
* Book n. Ch. i. Sect. gcl.
+ Part i.  Sect. iii. 
GE. I.-SP. I.]       SANGUINEOUS FUNCTION.                169

pus  without ulceration in the  first stage of purulent opthalmy,
and  in  purulent inflammation  of the mucous membrane of  the
glans penis; and I remember having attended about twelve  years
since a gentleman in  Bedford Row, who  had irritated  the ure-
thra by  improperly introducing a bougie  into  the bladder,  and
about three  days afterwards  discharged with his  water not  less
than half a pint of pure  pus, which separated itself from the  wa-
ter, and subsided, and thus gave me an opportunity of examining
it minutely.   1 requested  Mr.  Cline's  attention  to this  case,  and
we saw not the slightest reason  for suspecting any ulceration  what-
ever.
   Genuine pus is peculiarly distinguished by its consisting of  white
globules swimming in a fluid, which to the eye has the appearance
of serum, but possesses characters of its own,  equally  different
from those of serum and of every other secretion we are  acquaint-
ed with ; and which render it coagulable in a saturated solution of
muriate  of ammonia,  which is  its specific  test.  Pus,  however, is
not globular at its  first formation, but a transparent fluid  of a con-
sistence  in some sort resembling jelly ; the globules are  produced
while it lies on the surface of the sore, usually, when  not exposed
to external air, in about fifteen  minutes after  its secernment   The
perfection of pus seems to depend upon the large  proportion  which
its globules bear to  its  other parts.   It is specifically heavier than
water, and approaches  nearly to that of blood.  It has a  sweetish,
mawkish taste, (apparently from its containing sugar,) very diffe-
rent from that of most other secretions.  After putrefaction it evinces
an acid.  Dr. Bruggmans, who has analysed it with much care, asserts
that it has an acid also  before putrefaction; but this has been deni-
ed by Sir Everard Home *  For a further account of its  chemical
properties, the  reader may consult Dr. Pearson's  elaborate  paper
on this subject in the Philosophical Transactions.!
   In the process of the natural cure of an aposteme, we find that the
stage of granulation, and  consequently of incarnation,  immediately
succeeds  that of ulceration  or the removal of the  dead matter.
" The vessels," says Mr. Hunter, " forming themselves into  a cer-
tain structure which fits them for secreting  pus, it is so ordered
that the  same structure also fits them for  producing granulations;
and thus these two  processes  are concomitant effects of  the same
cause, which cause is  a peculiar organization superadded  to  the
vessels of the part."|
   The idea of a change of organization is  hypothetical, but inge-
nious, and perhaps correct.  Change of action and  change of effect
  * Dissertation on the Properties of Pus, p. 20.
  t Vol. 1809, p. 313.  See also a further description under Marasmus Phthisis
in the sequel of the present volume.
  X On Inflammation.—Of Pus, p. 433-
  VOL. n.             22 
170                     h*:matica.           [cl. iii.-or. ii.

we know ; but at the rest we can at present only give a guess, and
must leave it to  future times to ascertain.
   The obvious  design of granulation  or  incarnation, as it is often
called, is that of repairing the loss the parts have sustained by the
injury done :  it is  that of producing new flesh.  Granulation, like
vegetation, takes place  from the  centre  below,  in  a direction up-
wards toward the skin; and hence exactly contrary  to the course
of ulceration, which alway  begins in the superior part of an ab-
scess.  The process commonly succeeds best upon exposure to the
air, or at least after an opening  externally;  though there are in-
stances of its having  occurred where there has been no exposure
whatever.  The granulating pullulations, according to Mr. Hunter's
explanation,  consist of exudations of coagulating lymph from the
vessels.  He  conceives it probable not only that the  old vessels ex-
tend into these  pullulations and become elongated,  but  that new
vessels also form in them, and, like the old, still continue to secrete
pus.  The granulations,  as  they  become formed, mutually  and
readily unite; in osculation  or the attraction of cohesion is estab-
lished between them; and their vessels thus joined are transformed
from secreting into circulating tubes.   Immediately upon their for-
mation, cicatrization seems  to be in  view.  The  parts which had
receded, in consequence of a breach being made into them,  begin
now from their natural elasticity, and probably from muscular con-
traction, to be brought together by the new-created substance ; and
the contraction of the sore proves a sign that cicatrization is speedi-
ly about to follow.  This contraction takes place  in every point,
but principally from edge to edge, which brings the circumference
of the sore towards the centre : so that the exposed surface becomes
smaller and smaller, even before there is any formation of  a new
skin.
   There are two  parts,  at  least,  of  this wonderful  economy that
still demand explanation.  The first is the real use  of the pus after
it is secreted; and the second, the means by which  the absorbents
carry off the dead matter.   The  same  explanation  may  perhaps
apply to both.
   That pus is a peculiar secretion distinguished by peculiar pro-
perties, and  not a solution of the dead  animal  matter which it is
the design of nature to remove, has already been sufficiently shown.
" But I am apt to believe,"  says Mr. Hunter, " that  we are not yet
well, or perhaps not at all, acquainted with its use, for it is common
to  all sores; takes  place in the most  perfect degree in those sores
which may be said to be the most healthy, and especially in those
where the constitution is most healthy."*  It  forms,  indeed, an
exit to  foreign  bodies: is supposed by many  to carry off humours
from the constitution, or convert general into local complaints ; and
by others  to act as a preventive of numerous diseases.   Yet all
these services,  even admitting  them to exist,  are but secondary,
and the final  intention still remains to  be  accounted for.
* On Blood, &c. Part 11. Ch. v. p. 4S6. 
GE. I.-SP. I.]       SANGUINEOUS  FUNCTION.               ]7l

  In like manner, since the dead matter of an aposteme does not
constitute the pus that is found in it, and hence can only be carried
off by  absorption, we have yet  also to learn by what means it be-
comes  prepared  for an entrance into the delicate mouths  of the
absorbent vessels.  There is no small difficulty in conceiving how
these very minute mouths can apply themselves with sufficient ac-
tivity  to the various tough and hard substances  they have to re-
move,  as tendon and bone, when in close contact  with them ; but,
as soon as the dead part becomes separated from  the living,  they
are often no longer in close contact with them, except at the base,
where there is little or  no absorption  at all; and in many cases, as
in boils, carbuncles, and  other imperfectly  suppurating tumours,
possessing cores or tenacious sloughs, are at a considerable distance
from them,  with the entire body of the contained pus  placed inter-
mediately in the hollow.
   In the last case it seems impossible for them to act except through
the medium of the pus; in reality except through a  solvent power
possessed by the pus and exercised upon the matter to be removed.
And if such  be the nature of the action in this case,  it is doubtless
the nature of the action in all other cases: and hence we arrive at
one immediate and direct use of pus, which is, that of becoming a
solvent of the dead animal matter that requires to be carried off: not,
indeed, by converting the whole substance at once into a  fluid mass,
and still less into a fluid mass of its own nature,  as supposed by Sir
John Pringle,  but only the surface of the substance to which it is
applied; and which hereby is rendered fit for absorption, carried
forward to the  mouths of the imbibing vessels, and absorbed ac-
cordingly.   And  as the  same  power is exerted in succession upon
every  fresh surface of the  dead  matter that becomes exposed to its
action, the  whole is at length carried away, and a cavity produced
where before was solid  substance.
   That pus first kills and  then dissolves the organized matter of an
abscess was, as we have already seen,  the opinion of Mr. Hewson.
In the first part of this opinion he was completely mistaken; for, as
we have already observed, the organized matter is dead  before the
process of suppuration even  commences ; in the second,  he seems
to a certain extent to have been correct,  though he still erred in
supposing  the  dead substance to be  melted down into its own na-
ture,  and was unacquainted with  the important  process of its ab-
sorption.  But  in advancing his own full and more elaborate hy-
pothesis against the mistakes of Mr. Hewson's, Mr. Hunter ran into
the  opposite extreme ;  and contended,  that pus is not designed to
be a solvent at all, and  that animal substances  are decomposed in it
with very great difficulty: thus leaving us totally  at a loss to ac-
count  for its use ; and equally so to explain the manner in which
the  mouths  of the absorbents of an  abscess  can  operate upon or
even, in many instances, get at  the material they are to  remove.
   Mr. Hunter, however,  with the candour that so  peculiarly be-
longed to him, made this question a subject of experiment, and the 
172                     HyEMATlCA.           [<*' '"--°R- «•

experiment, as he  conceived,  fully established  his Pre-conc^e^
opinion :  and gave proof that the pus of an ab«e«  doe« not act as
a solvent.  This conclusion of his only shows how dtfficatt it is tor
the most  honourable mind, when biassed by a favourite hypothesis
to weigh with an even hand the evidence that lies before it     I o
see," s°ays he,  « how far the idea was just  that dead animal matter
was dissolved'by pus, I put  it to the trial of experiment be cause  I
could put a piece  of dead animal matter of a given  weight into an
abscess, and which could  at stated times  be weighed.  To  make it
still more satisfactory, a  similar piece was put into water kept to
nearly  the same heat.   They both lost in weight; but that in the
abscess  most.  And there was a difference in the manner, for that in
the water became soonest putrid."*  There is nothing in animal
chemistry,  strictly so called, that decomposes animal substances so
rapidly as putrefaction.   And yet in the  present instance the pus of
an  abscess evinced  a more active decomposing power  than the
fluid of water,  though aided  by the accessions of putrefaction.  It
is not  very wonderful  that Mr.  Hunter, though  regarding  this re-
sult as  in his favour, should not  be disposed to  "  rely on its accura-
cy," and  he refers us, therefore, for a further proof to a more com-
petent  experiment of Mr. (now  Sir Everard) Home, which consist-
ed in immersing a portion of muscle weighing exactly one drachm,
" in the matter of a compound fracture in  the arm of a living man,
and a similar portion into some  of the same matter out of the body ;
also a third portion into fluid calf 's-foot jelly, in  which the animal
substance was  pure, having neither  wine nor  vegetables  mixed
with it.  These portions of muscle were taken  out every twenty-
four hours, washed  in water, weighed,  and returned again."
   The result of this experiment is still more in favour of the sol-
vent power of pus  than  the preceding.  At the  end of forty-eight
hours  there was  indeed no great difference, as the muscle in the
abscess  was reduced  to  thirty-eight grains, and that  in the other
two fluids to  thirty-six.   But from this period to ninety-six hours
the  muscle in  the jelly  continued the same,  while that in the ab-
scess was  reduced to twenty-five  grains ; and that in  the exposed
pus dissolved ;t the power of putrefaction, as Mr.  Hunter  observes,
being in this last case superadded to that of the pus itself.
   We  hardly stand in  need of other experiments.  The solvent
power of pus above that of water, of animal jelly, and hence we
may conclude of animal fluids in general,  is sufficiently established
by the very evidence that  is advanced in  opposition to this power.
And it should  hence seem, that one at least of the direct uses of pus
is to reduce, surface after surface, the dead animal matter which  is
exposed to its action, to that state in which it may  be rendered fit
for absorption, and at the same time conveyed to the mouths of the
absorbent vessels.
* On Blood, &c. Part n. Ch. v. p. 419.
t Dissertation on the Properties of Pus, p. 32. 
GE. I.-SP. I.]        SANGUINEOUS FUNCTION.              173

  But I have for many years thought that it has also another equal-
ly important use ; that, 1 mean, of assisting in the process of granu-
lation ; and a late article of Sir Everard Home in the Philosophical
Transactions,  containing the  observations of Mr. Bauer upon the
germination of plants, and his  application of those observations to
the growth  of the new vessels in animals,*  seems, if not  to have
settled  the  question,  at least to  have very  considerably favoured
this view of it.                                        . .
  Having sown a quantity  of wheat for the purpose of noticing the
changes which occurred from the first, Mr. Bauer  took up every
day several grains or  plants  for examination till they  were ripe;
and in the course of his attention, was much struck  with the rapid
increase, of the tubular hair of the root  of a young plant of wheat
in its earliest stage of vegetation; and, fixing his view entirely to
 that part of the plant, he observed  small pustules of  a slimy sub-
 stance  arising under  the  epidermis in the surface of the young
 root; and in  a few seconds a small bubble of gas bursting from the
 root  into the slimy matter which it extended in a moment to the
 length the  hair was  to acquire;  when the slimy matter surround-
 ing the gas immediately  coagulated  and  formed a canal.  He re-
 peated  his observations on  another plant, whose pubescence con-
 sisted  of a1 jointed hair,  and observed  the  same effect;  a bubble
 issued  from  the young stalk, and extended the slimy mucus to a
 short distance, forming the first joint, which immediately coagulat-
 ed and became transparent;  and at its extremity a new pustule of
 the same  slimy matter accumulated, into which, in a short time,
 the gas from the first  joint rushed : and thus, in a moment, a second
 joint was formed.  In  the same  manner, he observed, the forma-
 tion of the hairs often or  twelve joints take place.
    Impressed with  the importance of these facts, Sir Everard Home
 immediately began to inquire how far  the same course is pursued
 in the production of  new animal matter.  He first  ascertained by
 experiments  of Mr.  Brande, already noticed in the proem to the
 second class of this work,! that blood in a state of circulation con-
 tains a considerable  proportion of air, which, in the process of  its
 coagulating,  escapes  in the  form of carbonic acid  gas, and in its
  escape produces  bubbles as  in  the slime of plants ; and that it es-
  capes  equally from  the  coagulating blood of veins and arteries,
  from effused serum and from pus.  And in pursuing the subject he
  found that, on the coagulation of a drop of blood placed in the field
  of a  microscope,  an  intestine motion  occurred, and  a disengage-
  ment of a  something took place in different parts of the coagulum;
  beginning to show itself where the greatest number of globuies
  were collected,  and from thence  passing in every direction with
  considerable rapidity through  the serum, but not at ail interfering
  with  the  globules themselves, which had all discharged their co-
* Phil. Trms. 1818, p. 180-194.
t Vol. I. 304. 
174                    hjematica.            [cl. hi.-or. ii.
louring matter.  Wherever this extricated colouring  matter was
carried, a net-work immediately  formed, anastomosing with itself
on every  side through every  part of the  coagulum.  When the
parts became dry, the appearance of a net-work  remained unalter-
ed.   In some instances bubbles  were seen to burst through the up-
per surface of the coagulum;  this however  did not  prevent the
ramifications that have been described from taking place.  " When
this happens," continues  sir Everard, " in living  animal bodies,
from whatever cause, and in whatever circumstances it takes place,
no difficulty remains in accounting for  its afterwards becoming vas-
cular, since all  that is necessary for this purpose is the red-blood
being received into the channels of which this  net-work is form-
ed."  He  next proceeded  to  the subject  immediately before us.
" As the globules of pus," says he, " are similar  to those of blood,
I made  experiments upon  the  fluid in which they are suspended,
and found  inspissation produce the same effect on it as coagulation
does on the other; that a similar net-work  is formed and apparent-
ly by the same means, since if pus be  deprived of its carbonic acid
gas, (of which it contains a large quantity,) by  exhaustion in the
air-pump,  no such net-work takes place."
  Additional experiments  are still necessary upon this interesting
subject; but so far as they go,  they seem very  clearly to indicate
the important and double  use to which pus is subservient;  that it
acts as a solvent upon the dead matter, preparing it for absorption,
and as  a fomes for granulation and the production of new vessels.
  Nor let it be observed in opposition to this conclusion that we
are thus endowing it with incongruous and  contrary qualities ; and
that if it be erosive in the  one instance it cannot be nutrient in the
other;  for the animal economy presents us with various examples of
like effects, contrary indeed but not contradictory, produced  by one
and the same secretion on  dead and on living matter, for which we
need go no further than to the  very common operation of the gas-
tric juice ;  which, while the most powerful  solvent of dead animal
matter in the whole range of animal chemistry, is a healthy stimu-
lant to the living stomach, and even to other living organs; and has
successfully been applied externally for this purpose by surgeons, to
weak and  ill-conditioned ulcers, and employed by physicians as an in-
ternal  tonic in cases of dyspepsy and cardialgia. 
GE. I.-SP. II.]        SANGUINEOUS FUNCTION.              175
                         SPECIES  II.

               APOSTEMA  PSOATICUM.



 PAIN AND TENSION ABOUT THE LOINS,  SHOOTING  DOWN  THE  SPINE AND
   THIGHS ; DIFFICULTY OF STANDING ERECT ; FLUCTUATING ENLARGEMENT
   ALONG THE  PSOAS MUSCLE; APEX  OF  THE TUMOUR IMMEDIATELY  BE-
   LOW THE GROIN.

 This is one of the most lamentable diseases we can ever be called
 upon to attend.  It commences insidiously, and at the same time in
 parts so deeply seated as to render it very difficult to determine the
 place  of its origin; and  hence  the psoas muscle itself, the cellular
 substance interposed between the peritoneum and the loins, the lym-
 phatic glands near the  receptaculum chyli, and the lumbal  verte-
 brae have been pitched  upon by different writers.  It  is probable
 that most of these have formed the primary seat of affection in dif-
 ferent cases, and that the inflammation has  subsequently spread to
 one or more of the other parts.   The pain  at first is by no  means
 violent, and the patient thinks lightly of it; it is sometimes felt in
 the back rather lower than the region of the kidneys ; and sometimes
 as low down as the thigh.  From the  deceptive  manner of its  at-
 tack, medical advice, and particularly a free use  of  purgatives and
 the lancet, which might have been of essential service at first, is fa-
 tally postponed; and the symptoms are regarded as those of  an ac-
 cidental strain.  After the abscess is  formed, however, the pain, in
 most cases, increases considerably ; and the matter may be discharg-
 ed into the cavity of the abdomen, where it would soon be fatal.  On
 this account it obeys the law of instinct  we had lately  occasion to
 notice ; follows, in most instances, the course of the psoas muscle,
 and points externally a little lower than  the inguinal glands; or it
 passes down the thigh, where, however, it is apt to dissever the
 muscles and form sinuous abscesses.   Sometimes, though rarely, the
 matter passes through the muscles of the back, and is discharged in
 the loins ; and in a few instances it has been known to fall into  the
 cavity of the  back part  of the pelvis.  The abscess, therefore, is
 highly dangerous; since under the most fortunate  circumstances it
 is so long in pointing externally, even if it should make any visible
 pointing at all, that the  patient  usually sinks  under a hectic fever,
 produced by the local irritation.  While in most cases, in which it
 has made a  natural opening for itself, it  has been found connected
 with so many  deep sinuses, which cannot  be followed up, that the
 same effect ensues.
  No mode  of medical treatment has been found productive of any
good purpose ;  and the  case has  been,  in a very early stage  of the 
176
H^MATICA.
[ex. m.-oR. n.
suppuration, given over to the surgical practitioner.  Yet even here
different individuals have pursued  different  lines of conduct.   Mr.
Bell advises an early evacuation of the matter, lest the  bones should
become injured;  while Mr. Abernethy apprehends less danger from
its being suffered to remain, and at last evacuates it at  different in-
tervals, and by successive operations: by which means the cyst, in
which the  pus is principally lodged, may have an opportunity of
contracting; and  this, he thinks, it  has  a  greater tendency to do
than in abscesses  where the  inflammation is  more  violent.  He is
also attentive to close  the  opening  the  instant the matter is  dis-
charged, so as to  prevent any increase of the  inflammation by an
access of air.
  The  real cause of danger does not seem to  have been  hitherto
hit upon; but  it may probably be referred to that tendency to a ra-
pid  spread of  inflammation over  their  entire surface, which  Mr.
Hunter has shown to exist in all internal  cavities, and the hazard of
which is in proportion to the extent  of the cavity; a subject alrea-
dy touched upon in the discussion of puerperal fever, and which we
shall have other opportunities of illustrating  as we proceed, parti-
cularly in some cases of varicose enlargement of the  veins.  Now
in the disease before us we have not, it  is true, any natural cavity,
but we have an artificial  cavity of  long standing, and large  extent,
in a highly irritable state, and which is therefore peculiarly predis-
posed to run into  all the  fatal effects  of large  natural cavities, when
injured or otherwise rendered imperfect.  The author throws out
this hint, however, for future and general consideration.
                        SPECIES III.

                APOSTEMA  HEPATIS.

                   ^iiiscfss of the Sifter.

DIFFUSE  PULSATING TUMOUR IN THE  REGION  OF  THE  LIVER ;  PRECEDEB
         BY PAIN,  A YELLOW COUNTENANCE AND SHIVERING.

This is also a very fatal disease; and  usually terminates  in one of
the following ways:
  Firstly, The substance of the liver is gradually and almost entire-
ly absorbed from long continued irritation : the melancholy accom-
paniments of which are a tedious  icterical  marasmus, hectic fever,
great anxiety, and a sanious and fetid diarrhoea, which  is  the fore-
runner of death.
  Secondlyy The  abscess breaks internally  and discharges a sanious
pus into the belly; by which means the  rest of the viscera are af-
fected ;  and the termination is marasmus, acites, and dissolution. 
GX. I.-SP. III.]       SANGUINEOUS FUNCTION.              177

  Thirdly, The pus sometimes finds a passage into the biliary ducts,
and thence into the intestines; from these it is occasionally thrown
into the stomach and vomited in the form of a dark offensive mate-
rial : but far more generally it is carried downward and produces  a
violent looseness.  Acids and acescent medicines  may here palliate
for a time ; but the issue is always fatal.
  Fourthly, The enlarged liver becomes, in some cases,  united by
adhesive inflammation to the peritoneum, and the abscess opens ex-
ternally ; and, in this  case, there is a chance of cure.  The opening
should be  expedited  by a caustic, or the knife ;  and the cure will
greatly depend upon the nature of the fluid which is discharged.
  Fifthly, There is reason to believe, that in a  few rare instances
the matter is carried  off by absorption, when a healthy granulation
takes place, and a cure  is  completed without any  opening.   This
termination is more  reasonably  to be expected in  a constitution
otherwise sound, and where the liver has not been weakened or ren-
dered torpid by any former affection.   It is hence rather to be  look-
ed  for in a temperate than in a tropical climate, and in youth than
in advanced life.
   These cases may,  indeed be regarded  as  sequels of hepatitis ;
though it is possible  that pus  may be thrown into the penicilli and
biliary pores of the liver by a  metastasis from some other organ,
as it not unfrequently is into the tubules of the kidneys, and thence
conveyed to the bladder.   When the cure  takes  place without an
opening, it is  not always an easy matter to determine for a certain-
ty that pus has actually  been formed.  But sometimes we can  trace
a fluctuation;  and at other times  the  subsidence  of the  tension,
pain, and pulse, after one or two  severe shivering fits, may be re-
garded as sufficient indications.  In a case of this kind  that occurred
to me in a young gentleman of about thirteen years of age, the shi-
vering was so considerable as  to make the teeth chatter; and with-
in eight-and-forty  hours the pulse sunk from  a hundred-and-forty to
a hundred-and-twenty; and the abdominal tension  and tenderness
were considerably abated;  as  was  also the distressing cough  with
which he had  almost perpetually  been harrassed  for  some weeks.
He was put upon a tonic plan of columbo and sulphuric acid imme-
diately after this change, and recovered gradually.
VOL.  II
23 
178
H&MATICA.
[CL. HI.-OR. II-
                       SPECIES  IV.

               APOSTEMA EMPYEMA.

          aoiraemeut ot i&atter in the Qlhtnt

FIXT PAIN IN  THE CHEST; BREATHING  LABORIOUS, BUT  EASIEST IN AN
  ERECT POSITION; DIFFICULT DECUMBITURE ON THE SOUND SIDE; FLUC-
  TUATING ENLARGEMENT ON  THE  SIDE  AFFECTED;   DRY,  TICKLING
  COUGH.

To the symptoms enumerated in the above definition Hippocrates
adds,*  edema of the feet, hollowness of the eyes, and a gurgling
sound on shaking the shoulder.  Of these additional signs, the hrst
two belong rather to the hectic fever  that generally accompanies
empyema, than to the disease  itself.   The last has sometimes been
met with in  modern times.t  Dr. Cullen regards empyema as a mere
sequel of pneumonia, which with him includes inflammation ot  the
pleura, as well as of the lungs, but as it may take  place from in-
flammation of the mediastinum,  pericardium, or diaphragm, to say
nothing of that  from external injuries, and as  it is often  doubtful
what particular organ  is directly injured, a separate species seems
decidedly called for.   Goekel,  indeed, describes a  case in which
the pericardium was affected  in connexion with the  right lung, and
to such  an extent that  both were totally consumed.
   In some instances, there is  no organ  to which the pus can be re-
ferred as a process of ulceration;  and to such  an affection  Mr.
Hewson has several references.  " The cavities of  the pleura, pe-
 ricardium, &c." says he, " are sometimes  observed  to contain  con-
 siderable quantities of  pus without the least marks of ulceration.
 In one patient I found three pints of pure  pus in the pericardium
 without any ulcer either on  that  membrane  or  on  the heart.  In
 another the cavity of the pleura of the right side was distended
 with a pus that smelt more like whey than a putrid fluid, and the
 lungs were compressed into  a very small compass:  but  there  was
 no appearance of ulcer or erosion either on these organs or on the
 pleura;  but  only  under  the pus was a  thin crust of coagulable
 lymph."  We have already observed upon this secretion of imper-
 fect pus, and  it is not necessary to explain it any farther:
   Dr. Darwin relates  a singular case of empyema, in which the pus
 seems in like  manner  to have been produced without ulceration,
 though he  ascribes it indirectly to an abscess  in the  lungs.  " A ser-
 vant man after a violent peripneumony, was  seized with symptoms
  of empyema, and it was  determined, after some time, to perform
 the operation; this was  explained  to him; and the usual means

            * Ilt/x n*6»v, p. 476, 496.
            t Trecourt Memoires de Chfcugie, &c. 
GE. I.-SP. IV.]      SANGUINEOUS  FUNCTION.                179

were employed by his friends to encourage him, by advising him
1 not to be afraid.'  By which good  advice  he conceived  so much
fear that he ran away early next morning, and returned in about  a
week quite well."
  This should indicate that something may at times  be  accomplish-
ed  by internal medicines, though no  plan has hitherto succeeded
that has been devised by professional  skill.
  Nor is  the present the only case on record in which  the contain-
ed fluid has disappeared by metastasis.  It has passed off by the in-
testinal canal,* by the bladder,! and by the vagina,!  in the form of
pus ; and is said in one instance to have vanished on the eruption of
a scabies.§  It has also frequently passed  off, by an opening formed
by nature, and the patient  has recovered his usual health.   This
opening has commonly been between the  ribs, most usually between
the third and fourth, but in one instance  we  find  the abscess point-
ing and bursting under the scapula.||  Morgagni has recorded a sin-
gular case of a double empyema, a lodgement of pus being  formed
 on both sides.TT And Balme a still more extraordinary case, in which
 the pus entered  the cellular membrane and spread over almost the
 whole trunk.**
   When  the fluid is discharged by paracentesis, Hippocrates urges
 repeatedly upon the surgeon to evacuate it only by degrees ;TT and
 Borelli gives a case in which the patient seems  to have  sunk and
 been lost under a sudden evacuation alone.ft   There has  also been
 no small  discussion concerning  the  part of the thorax to which the
 scalpel may be most advantageously applied.  David,  in  his prize
 dissertation, advises near  the  sternum ;§§ Mr. Sharp between the
 sixth and seventh rib;||||  Mr. Bell wherever the pain or fluctuation
 may directlFIT
   Mr. Warner, whose success made it many years  ago a favourite
 operation in our own country, seems to have been  of Mr. Bell's opin-
 ion, and varied  the point of opening according to the nature of the
 case.  And so little danger did  he apprehend from the  use of the
 scalpel on any occasion, that he not  only evacuated in all instances
 * Kelner, Diss, de Empyemate. Helm. 1670.  Marchetti, Obs. 82. 89.
 t Buchr.er, Diss, sistens solutionem Empyematis per mictionem purulentam.
Hal. 1762.  N. Act. Nat, Cur. Vol. I. Obs. 5.
 X Schlichting, Phil. Trans. Vol. xlii. p. 70.
 { Hautesierk, Recueil. n. p. 239.
 || Hurten, Diss.de Empyemate.  Argeat. 1679.
 H De Sed. et Caus. Morb. Ep. xxn. Art. 13.
 ** Journ. de Medicine, Tom. lxvi. p. 244.
 tt n«/>/ Nou<r*v, II. p. 476. 1. 42.  ris/u vast iv8«l n*8w, P- 536. 1. 15,
 XX Cent. I. Obs. 72.
 ii Mem. pour le Prix de l'Academie, x>
 |||| Critical Enquiry, &c. Chap. vi.
 -TIT Surgery, Vol. ii. 390. 
180
HLEMATICA.
[CL. III.-OR. 11.
 the whole of the  matter at once,  but in one or two instances  ope-
 rated, where there was neither a polarized pain, nor fluctuation, nor
 visible discolouration, nor  any  external  sign  whatever, to direct
 him to one part rather than to another, or even to determine the real
 nature of the  disease; otherwise  than from the specific symptoms
 laid down in the preceding definition.
   In Mr. Warner's cases, about twenty ounces of pus formed  the
 average of discharge at the time  of the perforation :*  the patients
 usually found  instant relief; the pain, cough, and quickness of pulse
 diminishing, and the breathing becoming easier.   He  dressed  the
 wound  with a sponge-tent till there was  no longer  any discharge,
 and afterwards  superficially;  and in about six weeks the patients
 were discharged cured.  In this case it is perhaps more necessary
 to keep the wound open than in any other operation, since, till the
 ulcerated surface of the interior is completely healed, the secreted
 pus  is  apt  to accumulate,  and the operation  must be  renewed.
 Tents of all kinds  are very properly exploded in most  cases in the
 present day; but Mr. Bell has judiciously observed that in the para-
 centesis the old fashioned practice ought still to prevail.t
  Dr. G. Hawthorn has given an  instance of this  disease,  that  for
its  severity and danger, and particularly for its successful issue, is
well worth recording.^  The patient was thirty years  of age,  and
the disease had been brought on by exposure to damp night-air, in
a state of intoxication.  He suffered greatly from quickness  of pulse,
incessant cough, oppression,  and  dread of suffocation.  A distinct
fluctuation  was  perceived in  about three weeks from  the attack;
shortly after which he was a little  relieved by a discharge  of puru-
lent matter effused into the bronchial cells, and expectorated to  the
extraordinary  amount of five or six pounds daily, for many days in
succession, a fluid  of an intolerably offensive smell,  and putrid ap-
pearance.  He continued, however, to grow worse and weaker;
his feet and legs swelled; his  countenance was  ghastly and he had
 colliquative sweats.   About twelve weeks from  the attack  the ope-
ration was performed, nearly twenty pounds  of pus were discharged
 on the first day and night; and he  gradually  recovered.
  Riedlin operated with success twice on the same person.S
  The matter when discharged or examined on  dissection has been
 found, as may be easily supposed, of very different consistences; some-
times pure pus, sometimes cheesy, and sometimes gelatinous.   And
 the mischief to the interior of the chest has in some cases been very
 great.   Several of the ribs  have been found carious ;||  the lung on
  * See Phil. Trans. Vol. xlvii. xlvih. Li. as also his works in their collected
form.
  t Surgery Vol. u. ch. xxn. Sec. iv.
  X Edin. Med. and Surg. Journ. No. LXI. p. 513.
  i Linn. Med. Ann. v. Obs. 30.
  j| Heuermann, Vermichta Bemenhungen, ii. p. 217. 
GE. I.-SP. V.]
SANGUINEOUS FUNCTION.
181
the affected  side totally eroded ;* and in one case the pericardium
destroyed as well as the lung.f
                        SPECIES  V.

                 APOSTEMA  VOMICA.

                           Vomica.

DERANGED  FUNCTION  OF A THORACIC OR ABDOMINAL ORGAN ;  SUCCEEDED.
  BY  A  COPIOUS DISCHARGE OF  PUS INTO  SOME PART OF  THE ALIMEN-
  TARY  CHANNEL ; AND ITS EVACUATION BY THE MOUTH  OR ANUS.

The specific term is a derivative from the Latin vomo, " to eject,"
especially from the stomach, but not exclusively so;  and hence, on
the present occasion, it i? used in the comprehensive  sense in which
it is employed by Celsus, who applies it to a bursting of pus from
the liver, or any other large  internal organ, as well as the lungs.}
Sauvages  follows Celsus in this interpretation  Boerhaave and Cul-
len confine vomica  to the lungs, and this in a more restrained sense
than most writers;  for they limit it to what has been called, though
with no great accuracy occult vomica, " vomica? clausae."  Linneus
and Vogel,  on the  contrary, while  they confine the term to  the
lungs, explain it  by open vomicos  " vomicae apertae," in which  the
pus is thrown forth  profusely and suddenly.  One termination of the
hepatic  aposteme may be regarded as a  variety of this species,  for,
as we have observed, it sometimes issues in a discharge  of pus  by
the mouth or rectum.  Wherever it occurs, it appears to consist in
a conglobate  gland,  first enlarged by a strumous congestion,  and
afterwards slowly and often imperfectly  suppurating.  Vomicae vary
in size,  from the diameter  of a millet-seed,  to that of an orange.
The  smallest rarely  contain any fluid,  and sometimes not even a
cavity; but they are often highly  irritable, and maintain a very con-
siderable degree of hectic fever.  When ulceration has taken place,
and pus is secreted,  the irritability  frequently subsides;  the  pulse
improves, the febrile exacerbations are less frequent  and violent,
and the patient flatters himself he is recovering.  The  vomica at
length bursts and  disabuses him ;  he  sinks gradually from the quan-
tity of the daily discharge, and the confirmed hectic ; or, if the  dis-
ease be seated in the lungs,  and the cavity  extensive, he may be
suffocated by the  volume of pus that overwhelms the trachea.
* Kelner, Diss, de Empyemate. Helmst. 1670.
t Goeckel, Gallicinium Medico-pract.
X De Medicin. Lib. iv. Cap. viii 
182                    HJMAT1CA.           [CI- I»--°R- "'

  Bartholine gives a singular case of an occult vomica of^the lungs
that, accompanied with an asthma, produced great emacia:ion, bu
was fortunately cured by the wound of a sword, the point o£ which
passed between the ribs"and opened the  sac.   A ccmsideraWe low
of pus followed, and the patient recovered gradually  fiom the time
of the accident*
                     GENUS  II.

                     PHLEGMONE.

                         $$fileflmonu

SUPPURATIVE, CUTANEOUS TUMOUR; TENSIVE 5  GLABROUS J PAINFUL; AT
  LENGTH  FLUCTUATING, AND BURSTING SPONTANEOUSLY ; THE PUS UNI-
  FORM AND GENUINE.

Under the last genus we took a general  survey of the process and
economy of suppuration,  and noticed many of  the most extensive
and dangerous forms in which suppuration ever presents itself. We
are now advancing to inflammatory affections, consisting of tumours
of small extent, and either entirely confined to the integuments, or
dipping but a little way below them.
   The term phlegmon, from <pxiyu, " inflammo," was used  among
the Greeks for inflammation generally.   It has long since, however,
been employed in  a far  more limited sense by medical writers of
perhaps every school, though few of them have given a very clear
definition of the exact sense in which they have intended to  use it;
or perhaps have formed  such a sense in their own  minds.   Thus
Dr. Cullen makes it comprise a multitude of tumours  or tubercles of
different degrees of inflammation, some  suppurative, some  unsup-
purative,  some serous,  some  callous, some fleshy, some  bony; as
boil, minute pimple,  stye, stone-pock, abscess of the breast, and
spina ventosa, or carious  bone ; with many others altogether as dis-
crepant ; while by Sauvages it is limited, and far more correctly, to
spheroidal tumours, possessing redness, heat, tension, violent throb-
bing pain, spontaneously  suppurating.  Not  indeed  essentially dif-
ferent from the character now offered, and involving most of its
species.   Vogel, however, makes it a part of its generic character
that the inflammatory tumour,  in order  to be a phlegmon, must be
at least as large as a hen's egg;  while  Dr. Turton, in his useful
glossary, not knowing how to  reconcile the clashing descriptions
which are thus given of it, merely explains it after the Greek man-
* Hist. Anat. xiv. Cent. 6. 
GE. II.-SP. I.]
SANGUINEOUS FUNCTION.
183
ner " an inflammation," leaving the reader to determine the nature
of the inflammation according to his own taste.
  It is necessary, therefore, to come to something more definite;
and I believe that the character now offered embraces the common
idea of phlegmon;  or,  if not, will propose what should  seem to
form a boundary for it.  And thus explained, it will comprise the
following species:—

1. PHLEGMONE communis.           push.
2.---------PARULIS.             GUM-BOIL.
3,_________AURIS.              IMPOSTHUME IN THE HEAD,
4.  ---------. PAROTIDEA.          PAROTID PHLEGMON.
5._________MAMM/E.             ABSCESS OF THE BREAST.
6.---------BUBO.               BUBO.
7,  _________ PHIMOTICA.          PHIMOTIC PHLEGMON.
                        SPECIES I.

             PHLEGMONE COMMUNIS.

               jlusft.  Common JJhleflmon.

TUMOUR COMMON TO THE SURFACE; BRIGHT-RED ; HARD; DEFINED; HEM-
  ISPHERICAL ;  POLARIZED ; GRADUALLY  SOFTENING  AND BURSTING AT
  THE POLE.

In vernacular language this species is denominated a push; and  in
size has a near approach to a boil, or furuncle;  but essentially dif-
fers from it in having its pus uniform and mature, while that  of
the boil is always intermixed with a core.  It is commonly a mark
of high entonic'health,  or a phlogotic diathesis ;  and rarely requires
any other medical treatment than bleeding, or a few  cooling pur-
gatives.
   Where, however, pushes  appear in crops,  and especially in suc-
cessive  crops, they support  a remark we  had occasion to make in
opening the present order;  that in conjunction  with the  phlogotic
diathesis there is  probably  a peculiar susceptibility  of irritation;
since we frequently find persons in  the highest  health, with firm
and rigid fibres, pass great part, or even the  whole of their  lives,
without any  such affection as the present.  Such  susceptibility  is
far more common, indeed, to a  habit of an opposite character, but
it seems from this as well as  from other circumstances, not unfre-
quently to inhere in the temperament we are  now contemplating. 
184
HAEMATIC A.
[CL. in.-OR. II.
                         SPECIES II.

              PHLEGMONE PARULIS.

                         G?um=iJotl.

TUMOUR SEATED ON THE  GUMS ;  DEEP-RED; HARDISH J UNDEFINED;  PAIN
                           OBTUSE.

This is sometimes limited t<5 the substance of the gums; and some-
times connected with a caries of a tooth or socket.  In the first va-
riety it is a disease  of only a few  days duration, and ceases almost
as soon as it has burst or is opened: in the second, it will often con-
tinue troublesome till the carious tooth is extracted, or the carious
socket has exfoliated: or  the whole of its texture is  absorbed;  in
which case the tooth will become loose, and may at length drop out
spontaneously.
  Gum-boils,  and  especially where connected with a morbid  con-
dition of the  subjacent teeth, or their alveoli, rarely disperse with-.
out passing into the suppurative stage:  and hence the means  of
prohibiting this termination are usually tried in vain,  much time is
lost and protracted pain encountered.   For these reasons it is better
to encourage  than to repel the suppurative process, by warm  cata-
plasms or fomentation ;  and to open the tumour as soon as it begins
to point.  An early opening is of importance ; for, from the tough-
ness and thickness of the walls of the abscess, it is seldom that the
confined pus obtains a natural exit with sufficient freedom; while in
some instances the ulceration assumes a sinuous character,  or works
into the  substance of the  cheeks, and at length opens on  their ex-
ternal surface.  The worst and most painful gum-boils are  those
which  form on the dentes sapiential : the swelling  from the vio-
lence of the irritation, spreads rapidly and widely; so that the en-
tire  cheek is sometimes involved  in it, the neck indurated, and the
eye closed.
                        SPECIES  III.

                PHLEGMONE AURIS.

                Kmjjostnume in the f^eaU.

TUMOUR  SEATED  WITHIN THE EAR ; PAIN ACUTE, THROBBING; HEAT AND
  REDNESS SPREADING EXTERNALLY; HEARING DISTRESSINGLY KEEN, OR
  STUNNED WITH IMAGINARY SOUNDS ; ABSCESS BURSTING WITH THE SENSE
  OF A LOUD SNAP OR EXPLOSION.

The term imposthume, an ordinary English name  for this disease, 
GE. II.-SP. III.]        SANGUINEOUS FUNCTION.            185

is probably a corruption of aposteme : but it is not always  easy to
trace the origin  of popular names.  The species is often the result
of a morbid and  suddenly  suppressed discharge from  the ear, and
may be  resolved by the application of leeches, or a blister, in the
first stage  of the inflammation;  but if this have been  neglected,
narcotic cataplasms and fomentations will best ease the pain till the
abscess breaks spontaneously.
   This, however, is to suppose that the abscess lies in the external
ear, either in the passage  itself, or on the outer surface of the tym-
panum ; which is almost always the case.  When  on the latter, the
pain is very acute, from the great sensibility of the membrane : but
it generally runs with speed through the  ordinary progress, and
heals without trouble.   If the inflammation take place on the inner
surface of  the tympanum, or in  the labyrinth, it is a complaint of
more  serious importance from the lodgment of matter after the
abscess has opened.  There is reason to believe that the  matter has
sometimes been  absorbed : but dissections have proved that it has,
in some cases, been locked up for years, and formed an occasional
cause  of hardness,  or  hebetude of hearing.   In some instances it
seems  to have become acrimonious and to have ulcerated the tunic
of the internal cavity,  and rendered one or two of the small bone9
carious.


                        SPECIES IV.

             PHLEGMONE PAROTIDEA.

                   $3rotfir $;ilegmon.

TUMOUR  SEATED UNDER  THE EAR; REDDISH; HARD; PAIN OBTUSE; SUP-
                  PURATION SLOW  AND DIFFICULT.

It is not a little singular that Dr.  Cullen, who extends the genus of
phlegmone wide enough to embrace, not only inflammation of the
ear, and of the breast, gum-boil, and phimosis, but also furunculus,
varus, gutta rosea, stye, and, as already observed, several affections
pf the bones, should have banished suppurative inflammation of the
parotid and  inguinary  glands, not only to another genus, but to a
very remote part of his system; where they occur, in the class and
order of local tumours, in company  with warts, corns, and sarcomata,
which have naturally no inflammatory character.   Here, too, they
are conjointly described under the generic name of bubo, with the
generic character of " glandulae conglobatae tumor suppurans ;" a
definition which  does not apply to the parotid  gland, whose struc-
ture is  not conglobate but conglomerate.  The present, therefore,
is  the  proper genus for including suppurative inflammation of the
parotid and inguinal, as well as of the mammary glands
  VOL.  II.                     24 
186                    MKATICA.             [<*' "»--OR- "'

   Phlegmonous  inflammation  of the  parotid gland offers us  the
two following  varieties :—
. Simplex.                      Incarning and cicatrizing easily.

fi M!dignaPar0tld Plegm°n'        Accompanied with a foul slough,
  Malignant parotid phlegmon.       and incarning with difficulty.
  In the simple or benign variety, though the suppurative process
is slow and inactive, the  incarnation subsequent upon the breaking
of the abscess is regular and unobstructed.  I was  lately requested,
in consultation, to see a young  lady of fifteen years of age, who has
been troubled  with this  species of phlegmon  for  more  than  three
months ; about a fortnight ago there was an evident pointing towards
the surface, and a feel of irregular fluctuation ; it has since broken,
a large quantity of good pus has drained away daily, and the tumour,
which at  first  was extensive and hard, is very considerably dimin-
ished, and clustered or divided into lobes, and  will, no doubt, shortly
disappear altogether.  Her general habit is  relaxed, but does  not
seem to be strumous.  She menstruated earlier than usual, and is of a
disposition peculiarly sprightly and  cheerful.   The local treatment
at the commencement was leeches, frequently  applied, and alternat-
ed  with  mercurial plaster.  But no benefit  proceeding from the
discutient plan, lotions of half water and half liquor, ammoniae  aceta-
tis  were afterwards employed to aid the suppurative process.
   The abscess in some cases of this variety is of considerable mag-
nitude, and consequently the discharge of pus very large.   And we
have some instances on record  in which the pus has been absorbed
and carried off by metastasis to some remote  organ.   Dr. Saunders
gives a  case  in which  it  passed away by the rectum ;* Alix, by a
fontinel at the navel ;t and the Transactions of Natural Curiosities,
by the bladder.J  It has sometimes  been confounded with parotitis
or mumps; and has hence been said to sympathize with one or both
testicles in males, and to  be contagious.  Cavallini has made this
mistake in his collection of surgical cases ;§ and we find a like error
in  the Memoirs of Toulouse.||
   The second variety of parotid phlegmon is  of a malignant charac-
 ter.  It seldom appears in early life, and in females seems sometimes
 to  follow upon the cessation of the catamenia.  It is still slower  in
 its progress than the preceding; and  when at length it breaks, the
 pus is  imperfect and cheesy,  or serous.  It is also profuse and
 protracted to  a long period and accompanied  with  foul sloughs.
 The patient is debilitated by the discharge, the  irritation excites
 hectic  fever,  and the  case frequently terminates  fatally.   Bark,

     * Observations on the Red Peruvian Bark.
     t Obs. Chirurg. Facie. I.
     X Vol. i. Obs. 39.
     } Collezione di Casi Chirurgici, I. 447.
     || Hibtoire et Memoires  de 1' Academic de Toulouse, Tom. I. 1782. 
GE. U.-SP. IV.]
SANGUINEOUS FUNCTION.
187
hyoscyamus,  conium, and  similar tonics and narcotics have been
tried ;  but for the most part with little success.
  It assumes, occasionally, a scirrhous  hardness,  and grows  to  a
considerable  extent.   It has been  extirpated  but  with variable
success, when upwards of three pounds in weight ;* sometimes  with
a cure ;t but  at other times it has degenerated into  a  foul, bleeding,
extensive, and fatal ulcer.J
                        SPECIES V.

                PHLEGMONE  MAMMAE.

                   ^hstess  ot the  Breast.

TUMOUR SEATED IN THE  BREAST J  TALE RED ;  HARDISH J IN IRREGULAR
  CLUSTERS ; WITH A PRICKING AND ACUTE PAIN ; SUPPURATION QUICK AND
  COPIOUS.

This is sometimes produced by some accident, as that of a blow or
6evere 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 virxeyxu, " 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 sctrrhoso trium cum quadrante librarum glan
dulae Parotidis extirpata.  Jen. 1752.
  t Siebold, Parotidis scirrhosse feliciter extirpata? Historia, Erf. 1791.
  X Commerc. Lit. Nor. 1733-8.
  } Hunter, on Blood, p. 469. 
188                     HvEMATICA.           [CL. HI--'
diseases supposed to depend upon an overflow, suppression, mis.dl"
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 ot  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.

                           13uho

TUMOUR SEATED IN A CONGLOBATE GLAND ; REDDISH ; HARD ; DIFFUSE ; NOT
        EASILY SUPPURATING J  OPENING WITH A CALLOUS EDGE.

Bubo is a Greek term borrowed from the Hebrew verb yi or Hy3
(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  buboe  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. II.-SP. VII.]     SANGUINEOUS  FUNCTION.              ] 89


                        SPECIES  VII.

             PHLEGMONE  PHIMOTICA.

                    Piimotic pursmou.

TUMOUR SEATED IN THE PREPUCE ; DIFFUSE ; OBTUSELY PAINFUL ; IMPRISON-
          ING 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 canftot be drawn back  and the  glans is
imprisoned.  If it should accidentally have been retracted, or be
naturally 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:

x Incarcerans.                 The prepuce protracted and impri-
   Incarcerating phimosis.        soning the glans.
C 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 blfenorrhaea.  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 Anweisung alle venerische Krankheiten—zu behandeln.
A.D.B. xcv. 421. 
 190                     HEMATIC A.            [CL- HL-OR. "•

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  smaller 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.

                          STuberele.

SMPERFECTLY 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
$v«, " 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 I'aulus of iEgina, 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  ventricle: 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.  Linneus and Cullen have reject-
ed  it.   Sauyages 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 suppurative and
glandular tumours; and, as a genus, it  thus occurs in Dr.  Willan's

  * Andree, on the Gonorrhoea.—Hecker, Von Venerischen Krankheisten, &c«
  t Vol. v. Art. xxxvi.
* 
GE. III.-SP. I.]       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 U:—

1. PHYMA HORDEOLUM.               STY.
2.------FURUNCULUS.               BOIL.
3. ------ SYCOSIS.                   FICOUS PHYMA.
4.------ANTHRAX.                  CARBUNCLE.



                         SrTCIES I.

                PHYMA HORDEOLUM.



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 writers, 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 old 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:  attd 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. 
DJSMATICA.
[CL. IH.-OR.  If.
                        SPECIES  II.

              PHYMA  FURUNCULUS.

                            ffot'1.

TUMOUR  COMMON TO THE SURFACE ;  DEEP-RED ;  HARD ',  CIRCUMSCRIBED j
  ACUTELY TENDER TO THE  TOUCH ;  SUPPURATING  WITH A  CENTRAL
  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.           ..      A
  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.

                     iPtcous pigma-

TUMOUR EXCRESCENT, FLESHY J  FIG-SHAPED ; SPROUTING FROM THE HAIRY
  PARTS OF THE HEAD OR FACE J  GREGARIOUS ; OFTEN COALESCING ; DIS-
  CHARGE PARTIAL AND  SANIOUS.

The Greeks gave the name  of sycosis from ovkoi " 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. Batenum 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
discharge 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
fetid 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.

                         GTarlmnele.

TUMOUR  COMMON TO THE SURFACE ; FLAT ; FIRM ; BURNING ; PENETRANT ;
  LIVID  AND VESICULAR ; OR  CRUSTY  ABOVE,  WITH A  SORDID GANGRE-
  NOUS CORE BELOW ; IMPERFECTLY SUPPURATIVE.

Anthrax is a Greek term correspondent to the Latin carbunculous or
carbuncle;  literally a small live-coal, so denominated from the red-
ness 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. n.                Sfc                    . 
194                    h^matica.            [cl. iii.-or. ii.
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 most common in those that have lived well.  I
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 we
have here, therefore, another striking proof  of  the  influence of
idiosyncrasy,  or a peculiarity  of constitution upon the general laws
and 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.
6 Terminthus.       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 spinosa, -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 rtyuitof of the Greeks, the pinus Abies,
Linn, named  by the Latins terehinthus; 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 go6d 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. Partfc. Ch. iv. 
GE. I1I.-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 jim-
merat.
  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.X)  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 «s 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 Pouteau the
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.

                         IONTHUS.

                           sarheift.

UNSUPPURATIVE, TUBERCULAR TUMOUR ; STATIONARY ; CHIEFLY COMMON TO
                           THE  FACE.

Ionthus (u»i«s) is literally a " violet, or purple eruption, or efflores
* Pare, Lib. xxi. cap. 32.
f  Buchoz und Marquet neueste Heilkunde, Niirnb. 1777.
t Riverius, Observ. Med. lent. iv. 
196                     H&MATICA.           [CU. III.-OR. II.

cence," from t»,  viola;  whose colour is frequently that of the
whelky or bubukled face.  It includes all those firm and indurated
pimples, of whatever description, unconnected with fever, and hav-
ing a  subcutaneous base, with which the face is often  disfigured,
whether solitary, gregarious, or confluent.  These may be compre-
hended under the two following species :—

1.  IONTHUS VARUS.            STONE  POCK.
2.-------CORYMBIFER.      CARBUNCLED  FACE.  ROSY  DROP.
                         SPECIES I.

                   IONTHUS  VARUS.
                                             *
                        Stone=jioefe.

TUMOUR  RED? HARD;  PIMPLY;  DISTINCT;  GREGARIOUS;  SORE  TO THE
       TOUCH J SOMETIMES OOZING A LITTLE FLUID AT THE TIP.

This sort of pimply eruption is so common that there is no one but
has seen examples of it; and few who have not at times given ex-
amples of it in their own persons.  It exhibits two varieties :—

x Simplex.         Broad-based, bright-red, solid.
  Simple Varus.
g Punctatus.        Tipped with a  black dot, and discharging, on
  Maggot-pimple.     pressure, a grub-like concretion of mucus.

  The first, on being firmly pressed with the finger,  oozes at times
a little limpid serum, but no concrete mucus; and  even for this it is
necessary to make the pressure harder than for the discharge of the
mucus in the maggot-pimple.  The mucus concretes in  a follicle, or
natural passage ; and hence there is less inflammation and soreness
than in the simple varus : yet the sides and root of the  follicle are
thickened and indurated : and hence the papulous  elevation.  Gou-
land's lotion and a few other empyrical cosmetics,  as  white  paint of
bismuth or  cerusse, alike deleterious in their effects, and apt to pro-
duce palsy, are a common resource among  the  multitude for  both
these varieties.  They have sometimes succeeded, with little other
sacrifice than the exorbitant price which the purchaser has had  to
pay for them; but the cure has  far more frequently been  bought
(if there have been a cure at all) at an expense of a ruined consti-
tution, and  the exchange of a  temporary local disfigurement  for a
life of general ill health.
  Both varieties are occasionally produced  by some internal  affec-
tion, chiefly of the stomach; as  acrimony, or a sudden chill from 
GE. IV.-SP. I.]      SANGUINEOUS FUNCTION.              197

taking a draught of cold water or cold milk ; or eating cold vegeta-
bles, as turnips, cucumbers, and  melons, when in a state  of «rreat
heat and perspiration.  Catching cold in  the  feet  has  sometimes
produced the same effect.   These are cases of direct sympathy : the
torpitu.de  of  one organ being communicated  to  another  which is
predisposed to associate in its action.
  They have occasionally yielded to powerful sudorifics, and espe-
cially when combined with  narcotics, as Dover's  powder in  strong
doses taken for several nights in succession, the part affected being
at the same time wrapped in flannel.  They have also  yielded  to
metallic and terebinthinate  stimulants,  as eight grains of  Plummer's
pill, and a scruple of camphor made into six or eight pills, and taken
daii*  Hjr ten days or a fortnight.  But they generally require some
locdi  irritant  at the same  time, as  savine  cerate, the  camphor or
mercurial  liniment, or the^tronger liniment of ammonia, used so  as
to e\cite blistering.  Yet after they have resisted these and other
preparations with great obstinacy for years, they have at length va-
nished beneath a severe attack of fever: or have disappeared #pon-
ta^eonsly.  The  complaint, however, is  occasionally  hereditary,
and bids equal defiance to» time, to fevers, and  to medicines.  Dr.
Darwin, under the name of gutta rosea, has a copious collection  of
cases in point; some of them drawn from old maids, and others from
elegant young ladies,  and  each  duly  authenticated with initials, to
which the  reader may turn at  his  leisure.  Among the rest is that
of " Miss L. a young lady about eighteen, who had tried variety of
advice for pimplefover the greatest part of her face, in vain.  She
took rhubarb  five grains, and emetic tartar a quarter of a grain, eve-
ry night for many weeks, and blistered her face by degrees all over,
and became quite beautiful."*
                        SPECIES  II.

              IONTHUS  CORYMBIFER.

              <£arimnclett=*ace.   Ifcosg  Uroj).

TUMOURS CONFLUENT; CORYMBOSE J  MOTTLED WITH  PURPLE; OFTEN  DIS-
          FIGURING THE NOSTRILS WITH PENDULOUS  LOBES.

As the preceding spedes is produced by a sympathy of excernents
of the skin with a torpid state of the stomach, the present is produc-
ed by a like sympathy with the liver: and hence it is proverbially
regarded as a proof that those who are thus disfigdred, have indulg-
# Zoonom. CI. n. I. iv. 6. 
198
HiEMATlCA.          [CL. III.-OR. II.
ed too largely in wine  and other spirituous  potations.   So Shak-
speare, in describing the physiognomy of a hard drinker, tells us that
«his  face is all bubukles, and whelks, and  knobs,  and flames of
fire !!"  And, in like manner, as I learn  from Dr.  Perceval, the
common name for these protuberances in Ireland is grog-blossoms.
  The tumours in this species  are usually more susceptible of irri-
tation than in the preceding; or, in other words, the cutaneous ves-
sels are in a state of increased  debility ;  and hence they are exacer-
bated by  cordials or exposure to heat.
  As this is, in most cases, an habitual affection,  or one  of long
standing, no change of diet, however desirable, should be made sud-
denly, for this would run a risk of producing  dropsy, and, perhaps,
paroxysms of atonic gout:  but  a gradual  change to a more sober and
temperate regimen is highly to be recommended : and in the mean
time the patient should have  his bowe|p kept regularly open with
warm eccoprotics, as the extract of colocynth and myrrh pill, and be
put upon a course of equitation, or such other exercises as may re-
cruit the  spirits and invigorate the system generally, in  which be-
nefit the liver will become a chief participant.  The tumours may
not, perhaps, totally disappear: but they«will  often diminish in mag-
nitude, and assume a healthier  hue : or at least we shall hereby pre-
vent them from any farther  enlargement, and especially from pass-
ing into that carbuncular ulceration we have just noticed.
                      GENUS V.

                         PHLYSIS.

ULCERATIVE,  SUBCUTANEOUS  TUMOUR ; FLAT ; TENSIVE ; GLABROUS ;  DIF-
  FUSED ; hot ;  throbbing ;  at length fluctuating with an acrid
  ICHOR.

Phlysis, from the Greek QXvZp, " ferveo," was formerly employed
in a very indeterminate  meaning  to  express cutaneous  eruptions
filled, with any kind of fluid, whether purulent  or ichorous: more
generally, however, it had a bearing towards the sense of ichorous
or vesicular  pimples.  Dr.  Willan has,  on this account,  correctly
limited  phlyctaenae, derjved  from the same root, to this import, in
his table of definitions: and such is the restriction of phlysis, and all
its compounds in the present system.
  Of  the genus now offered,  there is  but one  well-ascertained
species, the paronychia, or whitlow. 
GE. V.-SP. I.]        SANGUINEOUS FUNCTION.              199


                         SPECIES  I.

               PHLYSIS PARONYCHIA.

                          Wfutloto.

INFLAMMATION  SEATED ABOUT THE NAILS AND ENDS  OF THE  FINGERS ;
         PAIN  ACUTE AND PRICKING,  SHOOTING UP THE HAND.

Under this species are included the following varieties :

x Cutanea.                        Effusion immediately under the
  Cutaneous whitlow.                skin.
ft Tendinis.                       Effusion among the tendons.
  Tendinous whitlow.
y Periostii.        %             Effusion pressing on the perios-
  Malignant whitlow.                teum.

   In the first  variety, the  acrid eflusion is poured forth  between
the skin and the subjacent muscles, to  which, however, it is limited.
   In the  second, it insinuates itself between  the tendons and the
periosteum.   And in the third,  between the  periosteum and  the
bone, which is often, hereby, rendered  carious.   It is to this last,
or  malignant whitlow, that the term felon is most  correctly applied.
   Similar inflammations are occasionally  to be found in the soles of
the feet, and  palms of the hands;  they break through the skin or
cuticle  with  difficulty from their thickness ;  and hence become dif-
fused,  and, in the latter  case, separate  the  cuticle from the skin
beneath.
  In the  whitlow, the acute  and lancinating pain complained of
arises  partly from the thickness and  inelasticity  of the skin  about
the finger-nail, but more from the  hardness of the finger-nail itself;
both which act like a tight bandage upon the inflamed part, and do
not allow it to swell or give way to the extravasation.  In these cases,
 therefore, we can easily see why the application of poultices should
be of  more service than in any other;  for  they can here act me-
 chanically ; or, in other words, their moisture becomes imbibed by
 the cuticle, as by a sponge, so that it softens,  grows larger in its
 dimensions, and less  rigid in its texture : while the nail itself  loses
 a part of its hardness, and becomes suppler.  It is in consequence
 of the peculiar firmness of the  skin  around  the  nail that the soft
parts  below  are so  often  seen  pushing out through a very small
opening in the skin as soon as this has been effected, and appearing
like a fungus; but so exquisitely irritable as to give a more impres-
sive idea of soreness, than, perhaps, any other kind of ulceration
whatever.  All this proceeds from the  surrounding belts  of the
cuticle not giving way to the increase of the  parts underneath;
whence they  are squeezed out of  this small opening like  paint out 
200
H^MATICA.
[CL. III.-OR. II.
of a bladder.  It is a common practice to eat away this protruded
part by escharotics, as if it were a diseased fungus; but this is to
give additional pain without any benefit, for the pressure from below
will not be hereby  diminished.  By  continuing the  poultice,  the
tumefaction will subside, and consequently the pressure cease.
  In the first stage of the complaint leeches should  be applied,  and
if the inflammation be hereby diminished, it may sometimes be car-
ried off by astringent lotions, or ardent  spirits, which excite the sur-
rounding absorbents to  additional action.   Most of the  causes of in-
flammation operate in the production of this peculiar  affection.   It
is also occasioned by an incurvation of the nail ;* possibly sometimes
by a caries or morbid state of the subjacent bone  in the tendinous
and periosteous variety,  as asserted by  Siebold ;t and Mr. John Pear-
son has shown that it may occasionally result from  a syphilitic dia-
thesis, or any other depraved habit.|   It seems,  moreover, in some
cases, to be produced by the bite, or burrowing of the  larves of  one
or more minute, and, to the naked eye, invisible  insects, hatched
on the  leaves of various field  plants,  and  especially  fescue-grass:
and is said to be  also occasioned by the bite of the gordius aquaticus,
or hair-worm.
                      GENUS VI.

                      ERYTHEMA.

                   Knflammatorg Blusli.

RED, GLABROUS,  TUMID FULNF.SS OF THE INTEGUMENTS ;  DISAPPEARING ON
  PRESSURE :  TAIN EURN1NG ; INFLAMMATION  ULCERATIVE ; TERMINATING
  IN CUTICULAR  SCALES, OR VESICLES ;  OCCASIONALLY IN GANGRENES.

This genus of inflammation is entitled to a minute  and discrimina-
tive attention, not only on account of its violence and tendency to an
almost unlimited spread, but  from its having  been very  generally
confounded with an exanthem or eruptive fever which,  in one or
two of its species, it frequently accompanies, but of  which it is then
a mere symptom.
  Erythema, from tfivfos, rubor, is a term of Hippocrates, who uses
it as nearly as may be in the sense now offered; and  for which many
modern writers of our own country have not unaptly employed the
vernacular term inflammatory blush ; since the redness has often
* Vicat. Delect. Observ. Pract.
t Chirurgisches Tagebuch. xi.
X Principles of Surgery, P. i. 
GE. VI.]
SANGUINEOUS FUNCTION.
201
very much the appearance of a blush, or glowing suffusion of the
cutaneous capillaries.   For erythema  Celsus and Galen have un-
fortunately adopted  the term erysipelas, whence  Duretus, in his
Latin version of Hippocrates, has used suffusio  erysipelatosa.  And
hence  erysipelas has been made a very commom synonym of ery-
thema by general writers, while the nosologists, with a few excep-
tions, have limited  erysipelas to that species of exanthem or erup-
tive fever which is vernacularly known by the name of St. Anthony's
Fire ;  and have revived erythema to express the local affection, or
peculiar inflammation  before us, in which  the pyrexy is, merely
symptomatic.
  Frequently, however, as these two disorders have been confoun-
ded, from an indiscriminate application of the same name io both, it
will not be difficult to draw a distinctive  line between them.   Ery-
thema bears  the  same analogy to phlegmon,  as erysipelas does to
small-pox.  Phlegmon is local inflammation tending to suppuration;
erythema, local inflammation tending to vesication : small-pox is an
idiopathic fever producing a  phlegmonous efflorescence ; erysipelas,
an idiopathic fever producing erythematic efflorescence.  Small-pox
is always contagious; erysipelas occasionally so;  phlegmon and ery-
thema have no such tendency.
  The distinction then  between erysipelas and  erythema is clear;
yet the confusion, just noticed, has been increased by some writers
who  have not only used erysipelas in its  popular yet erroneous
signification of erythema, but have  also employed erythema in a
new and unjustifiable sense ;  as occurs particularly in  Dr. Willan's
classification  of Cutaneous Diseases:  where, while  erysipelas is
made to embrace both erysipelas and erythema, as these terms have
hitherto been common \y used, erythema  is arbitrarily appropriated
as the  name of another collection of cutaneous erubescences of very
different characters, and produced by  very  different causes; some
of them primary, others symptomatic affections;  some constitution-
al, and others local;  occasionally smooth, papulous,  tubercular, or
nodose ;  most of which should be distributed, under different  divi-
sions.
  Thus introduced  and explained,  erythema, as a genus,  will  be
found to comprise the six following species, the first three of which
are taken with little alteration from Mr. Hunter:

1. ERYTHEMA CEDEMATOSUM.         EDEMATOUS INFLAMMATION.
2.--------ERYSIPELATOSUM.       ERYSIPELATOl S INFLAMMATION.
3. ERYTHEMA GANGRENOSUM.         GANGRENOUS  INFLAMMATION.
4.--------VESICULARE.          VESICULAR INFLAMMATION.
5.---------PERNIO.               CHILBLAIN.
6. ————- INTERTRIGO.          FRET.

  Most of these depend upon a peculiar irritability of  the constitu-
tion,  or  of  the part in which the inflammation  or erythema ap-
  vol. n.                  26 
 202                    HiEMATlCA.            [CL. IH.-OR. II,

 pears;  and the  common, .though, perhaps,  not  the  sole cause of
 such irritability is debility or relaxation.
   Galen, who justly distinguishes  between  suppurative, or, as he
 calls it, phlegmonous inflammation, erythematic (with him erysipe-
 latous,) and edematous, ascribes  the  first, according to the old doc-
 trine of temperaments, to  a prevalence of the sanguineous diathe-
 sis ;  the second  to that of the bilious; and the third to that of the
 phlegmatic or pituitous *   That there is generally a peculiar habit
 in the last two, and often, as we have already observed, in the first,
 is so clear as to be indisputable :  but it  is by no means  equally
 clear that such peculiarity of habit is dependent  upon the immedi-
 ate cause Galen  has adverted toi  The temperaments of the Greek
 physicians, excepting when in excess, are not inconsistent with the
 condition of health; and  hence, therefore,  in connexion with the
 temperament there is usually, in the  last two inflammations,  a habit
 of debility or  relaxation.   And  where  this exists, the very same
 stimulus that in a perfectly healthy frame would produce a common
 adhesive  or suppurative inflammation,  under this state of the sys-
 tem  changes the character of the inflammatory action, and urges on
 the  ulcerative process from the first.   It usually commences with
 peculiar violence, and  is peculiarly apt to spread; the surrounding
 parts being easily excited  to act or sympathize in  an action to
 which they are  prone.  Hence, continued sympathy is a common
 though not an  universal effect;  for we  sometimes meet with  very
 considerable inflammations confined  to the part irritated, notwith-
 standing that the irritated part evinces great violence of  action.
 Mr. Hunter has  illustrated  this difference of effect  by referring to
 a piece  of paper under two different  states, dry «md damp.   In  dry
 paper a blot of ink applied to it will not spread,  and remains con-
fined to the point of  incidence; in wet paper  it spreads  easily,
being attracted  by the surrounding  moisture to  which it  has an
affinity.
* De Tumoribus, Prater. Nat. Tom. m. xx. 
GE. VI.-8P. I.]
SANGUINEOUS  FUNCTION.
203
                        SPECIES I.

           ERYTHEMA  (EDEMATOSUM.

                2£'acm<itoH.g Xuflammatton.

COLOUR SCARLET ;  SPREADING WIDELY  AND DEEPLY THROUGH  THE CELr
  LULAR MEMBRANE, WHICH OFTEN IMFERFECTLY SUPPURATES, SLOUGHSj
  AND  BECOMES  GANGRENOUS.

This is the  " edematous  inflammation" of Mr.  Hunter, who  ob-
serves, that, when the extravasatcd fluid is  water, it has very much
the appearance of the adhesive inflammation, and probably resem-
bles it more nearly than any other erythema, being of a scarlet co-
lour, but much more diffused.
   The skin, through  the whole range of the intumescence,  ap-
pears glabrous,  and the redness vanishes upon a pressure of the
finger, but returns as  soon  as  the pressure  is removed.  The ex-
travasated fluid  is  principally serum, and hence  the swelling
spreads wider  than the inflammation itself.  It is very painful, or
 rather very sore, but has  less of the sensation of throbbing than the
 adhesive inflammation.  It is apparently limited to the surface, yet
 it probably goes  much  deeper : for the extravasated  fluid is in too
 large a quantity to be furnished by the cells of the cutis alone : but
 as the swelling and the inflammation do not here keep pace with
each other as in the adhesive  description, we have  not the same
guide to  direct our  judgment.   Coincidently with the remarks al-
ready offered, Mr.  Hunter  observes that  " the difference between
this and  the adhesive inflammation arises,  I conceive, from the
principle of inflammation  acting upon a dropsical disposition, which
is always attended with weakness;  whereas a  greater  degree of
 strength would have produced the adhesive inflammation under the
 same  cause or irritation.  And what makes me conceive this, is,
 that in many cases of anasarcous legs we  have exactly this inflam-
 mation come on from distension, which adds to the extravasation of
 the serum, as well as in  most cases of scarifications of edematous
 parts to evacuate the water.  When  this  inflammation takes place
 it is much more lasting than the adhesive ;  and I believe, seldom
 or never produces suppuration : but if it should run into this stage,
 it is more general, and the whole cellular membrane  in the inter-
 stices of parts is  apt to mortify and slough,  producing very exten-
 sive abscesses, which are not circumscribed."*
   There is no difficulty in determining why  edematous inflamma-
 tion should rarely, if ever, produce suppuration,  and why it should
 be of longer continuance.   Suppurative inflammation is, generally
* On Blood, Part n. Ch. II. Sect. vii. p. 269. 
204
H/EMATICA.
[CL. III.-OR. II,
speaking,  the  process of a healthy part or habit taking'^ce in-
stinctively  for  the  purpose of  removing something  that is  dead
irritating; or otherwise mischievous,  and  of filling up.the  space
hereby produced  with sound living matter.  In edematous inflam-
mation the part or .habit is unhealthy,  and debilitated ;  and[hence
while there is necessarily less tendency to suppuration, there is less
power of recovery.                            ,           i .
  The general curative intention therefore may be expressed in a
few words.  It  should consist  in whatever has a fair  promise of
giving local or  constitutional tone, or  both.  Hence the benefit of
astringent epithems  and lotions whether formed of earths, acids,  or
metallic oxydes,  applied to the  part affected; and  of stimulants
where the action  is peculiarly weak, as camphor-water, or a solu-
tion of the  acetate of ammonia, with proof spirit proportioned to
the degree of  torpor.  And hence, as internal  medicines,  bark,
columbo, myrrh,  iron,  will  often be found highly serviceable, in
conjunction with  a  generous diet, pure air, and  such  exercise as
may be taken without fatigue.
                        SPECIES II.

        ERYTHEMA ERYSIPELATOSUM.

              asrsstjjelatous Xnflammatton

COLOUR DEEPISH-RED ;  SUPERFICIAL ; WITH A  DETERMINED EDGE IN A
  SERPENTINE  DIRECTION; THE PART WHICH HAS PASSED  THROUGH THE
  ACTION  HEALING AS THE PART NEXT  ATTACKED BECOMES AFFECTED.

This is the  " erysipelatous inflammation"  of Mr.  Hunter; and is
evidently  that which symptomatically  accompanies the erysipelas
as an exanthem,  or eruptive fever.   It is more commonly cutane-
ous  than situated in the deeper-seated parts; although in some con-
stitutions almost  every inflammation, wherever it  takes place, will
run deep as well as wide.  The skin, however, appears to be most
susceptible of its action;  for it will  spread  over  a prodigious sur-
face of skin,  while it rarely  affects even  the cellular membrane
underneath; and in this respect, especially,  it differs from the pre-
ceding species.  The extravasation  moreover is less  than either
in the  edematous or even the adhesive inflammation.  It appears
to support itself by continued sympathy ; for it commonly begins at
a point, and spreads  in a  migratory direction, as the  part first at-
tacked recovers.  This cannot, therefore, be merely constitutional;
for, if it were, the  parts already inflamed could not recover, while
the  morbid condition of the constitution disposes the surrounding
parts to the same action : but it affords an idea that, when the parts 
GE. VI.-SP. II.]      SANGUINEOUS FUNCTION.               205

affected h^*e once gone through the action,  they lose the disposi-
tion and become healthy.   This property is not peculiar to the in-
flammation  before us:  the  ring-worm  and many other cutaneous
affections have the same tendency.
  Mr. Hunter observes that this inflammation is more common in
the summer than in the  winter, especially in hospitals; and believes
that it takes place more frequently after wounds on the head than
any where else.   " I have often," says  he, " seen it begin round a
wound on the scalp, and extend over the whole head and face; the
eye-lids being very much  swelled and  the ears thickened;  it has
then advanced to the neck, shoulders, and body, creeping along both
arms, and terminating  at the fingers ends: the part which  attacks
the body  often descends to both thighs, passes down  the legs, and
terminates at the ends of the toes.   And while this is going on, it as
expeditiously cured behind,  and the skin peels off from the  cured
parts."   Sometimes, however, it stops  suddenly in its  course, and
assumes a milder character.
  If it proceed deeper than the skin into the cellular membrane, it
often suppurates, and at times occasions mortification in the cells
by  which  air is let loose ;  and it is this  state of the disease that
forms  the erysipelas phlegmonodes of  Galen,*  Van Swieten,t  and
many later writers, who have used erysipelas in the loose manner
I have already pointed out, as synonymous with erythema.  The
effect of this mixture of inflammations produces a strange feel, for
it is neither that of fluctuation nor of crepitation ; and, as there are
no  adhesions, the matter finds an  easy  passage into the common
cellular membrane, increasing the same  kind of suppuration where-
ever it goes;  and as mortification,  and consequently putrefaction,
follow speedily,  the  discharge  becomes very  offensive.  As  the
parts loaded with effusion seldom  ulcerate, they should be opened
early; for the fluid either gets into the cellular membrane from the
want of adhesions, or separates parts that are only attached, as the
periosteum from the bone, or muscles from muscles; while the tru&
suppurative inflammation, on the contrary, ulcerates briskly,  and
hence should be allowed to burst or at  least should not be opened
early.                                                    *
  At the  commencement of this inflammation there is commonly
some degree'of fever, accompanied with prostration of strength and,
dejection  of spirits, and especially with loss of appetite.   But the
fever soon subsides, while the inflammation pursues its course ; yet
since one source of irritation has thus departed, it is less  violent,
and sometimes assumes  a chronic character.
  As this,  like the last,  is a disease of weakness, the same general
tonic plan  will be calculated to oppose  it.; and, where there is a
tendency in the separated skin to crack, absorbent earths or pow-
ders should be scattered freely over the ulcerative or oozing parts,

           * Mat. Med. Lib. xiv. cap. ir.
           t Comment. Tom. n. * 723. 
206
ILEMATICA.
[CL. III.-OR. II.
to imbibe the acrid fluid as it escapes,  or the ulceration will soon
become extensive; and the feeble and inflamed subjacent skin,
hereby  exposed to  the stimulus  of  external agency,  will grow
gangrenous with great  speed.  Finely pounded starch is  a use-
ful powder for this purpose ; as  it combines a tonic and an astrin-
gent with  an  absorbent  power; so, likewise,  is  a  mixture  of
Iqual parts of  starch and finely  levigated calamine or  rhubarb.
The last I have sometimes thought peculiarly effectual in  check-
ing the irritation ; as the second appears to be in preventing the
further spread of the inflamed outline  that surrounds the separat-
ccl cuticle*
  This species of inflammation sometimes attacks infants from a ve-
ry early period after birth; and, what is more singular, they have
in a few instances been born with it.  In such cases it appears to  be
produced by some occasional cause, co-operating with an erythema-
tic diathesis derived  hereditarily.  It generally assumes the mixt
form of phlegmonous erythema ; suppurates imperfectly as it takes
its course  through the  cellular  membrane, and  is often succeeded
by gangrene.  Its progress is very rapid from the relaxed state  of
the infantile fibre : and from the extrication of air, as soon as gan-
grene is produced, the  tumified  surface  has  the mixed feel already
noticed of fluctuation and erepitation.  It commences usually about
the genitals, works its way below  towards  the  thighs and legs, and
above towards the abdomen, and often excites on the peritoneum the
same caseous or purulent secretion which  is so apt to form on this
membrane in puerperal fever.   As there is no disposition to adhe-
sion, the fluid spreads in every direction, wherever  the ulceration
makes a way for it; and hence it has often descended in great abun-
dance into the tunica vaginalis and labia pudendi.
   Stimulant epithems of ether, alcohol, and camphorated spirits, ap-
plied in the first stage  of the disease  to  the parts affected, have
been found the most  beneficial practice:  to which ought by  all
means to be added the  use of the bark in any  way in which it can
be introduced, especially in that of injections repeated several times
a day.
                       SPECIES  III.

         ERYTHEMA  GANGRiENOSUM.

                (Kawjvcuous Inflammation.

THE COLOUR DUSKY-RED; SUPERFICIAL ; CUTICLE  SEPARATED FROM THE
  CUTIS BY A BLOODY  SERUM ;  THE  CUTIS,  WHEN  DENUDED,  EXHIBITING
  DARK BROWN SPOTS, DISPOSED TO  BLISTER, AND  SLOUGH ;  OCCURRING
  CHIEFLY IN THE EXTREMITIES.
The gangrenous erythema, like the two preceding species, is a fre 
GE. VI.-SP.  III.]      SANGUINEOUS FUNCTION.             207

quent companion of debilitated or relaxed constitutions, but is most-
ly to be met with  in advanced age, or weakly adolescence, or in-
fancy ; and particularly where, in old age, the constitution has been
broken down by habits of intemperance and excess; the circulation
is languid, and the blood  even in  the arteries assumes a venous  ap-
pearance.  The inflammatory stage is in these cases sometimes ve-
ry slight, and the  gangrene is ushered in with very little previous
affection.
  £ither of the preceding species will pass readily into the present,
in*  warm,  stagnant, and corrupt air; for  the same reason that all
hospital wounds run  rapidly into the same state under the same cir-
cumstances, as we shall have to notice  hereafter.
   Local applications are  here of far less importance than an atten-
tion to the  general condition of the  constitution.   Stimulants and
perfect cleanliness are perhaps  all that are  demanded under the
first head ; while, under  the second, pure air, and a steady course of
tonic medicines and  diet, adapted to the. age and habits of the pa-
tient, are absolutely indispensable; and can alone furnish any hope
of recovery.
   How far this disease appertains to the ignis sacer of the  Roman
writers, will be seen under the ensuing species, which forms another
subdivision  of the  same affection.
                        SPECIES IV.

            ERYTHEMA  VESICULARE.

                    WzBitnlav 2£rgthema.

COLOUR PALE-RED;  SURFACE ROUGHISH, AND  COVERED  WITH  CROWDING
  MINUTE VESICLES, FILLED  WITH AN  ACRID, OFTEN A REDDISH FLUID $
  PROGRESSIVELY TRAILING INTO THE NEIGHBOURING SOUND PARTS.

This species admits of two varieties, which have been pointed out
from the age of Celsus.

    * Benignum.       Benign vesicular Erythema.
    /3 Corrosivum.     Erosive vesicular Erythema.

  In the first, the  redness and vesicles advance without a breach  of
the cuticle, as the part that  has  passed through  the  action  is
healing.
  In the second, the vesicles  break in the part first affected; and
the erosive fluid produces tracts of sanious ulceration as the redness
advances.
  Under the present and  the  preceding species  is  included the 
208
H;EMATICA.
[CL. III.-OR. II.
 ignis sacer of the ancients; about which much has  been written,
 but which has been seldom understood, and  never hitherto allotted
 a clear methodic position.  The author has taken some pains upon
 the subject, and trusts he will be able to establish the true bounda-
 ry and character of a disease, not more frequently described  by the
 physicians, than celebrated by the  poets of antiquity.
   The common error has consisted in making the  ignis  sacer, or
 holy fire, an  exanthem or eruptive fever ; an erysipelas or a pestis ;
 or some  other  idiopathic  fever   of the  same  order.   There^is
 no doubt,  indeed, that, like  the  erysipalatous erythema, it  has at
 times been met with as an accompanying symptom  in pestis; and
 when we come to treat of  this disease, a distinct notice will  be  ta-
 ken of the variety which such an accompaniment produces,  and of
 which the plague of Athens seems to furnish us with a tolerable ex-
 ample ; but the ignis sacer, in its genuine and simple  state, instead of
 being marked with a  low eruptive fever, has often very little fever
 of any kind;  certainly nothing more than symptomatic  fever; and
 by Celsus is described as being best cured by  an ephemeral or any
 other fever which may give increased action to the system ; hereby
 proving that  this, like the entire group of erythemas, is a result of
 debility.
   In ancient  times some diseases were supposed  to be inflicted  on
 mankind by the special interposition  of  the Divinity, or of his mi-
 nisters ;  and  to these was assigned  the  name  of sacer, or holy;
 though the peculiar crimes for which they were  inflicted,  or the
 names of the particular persons who in this  manner first drew down
 the special vengeance of  heaven upon  their atrocities, have not
 been communicated to us.  The later  term  of Saint, or Sanctus, as
 in St. Anthony's fire or St.  Vitus's  dance, are of parallel  origin, and
 express corporeal punishments, first inflicted by the agents or suppos-
 ed agents of the deity whose  names they respectively bear.   Ignis
 is a term expressive  of the  heat, redness,  acrimony, and erosive
 power of a 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  represents 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.  u It has," says
 he, " two species ; one (the vesicular erythema of the  present sys-
 tem) is reddish,  or a mixture of redness and  paleness, rough with
 approximating vesicles (pustulas,) 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 M-j .icin. Lib. v. Cap. xxvm. Sect. 4. 
«E. VI.-SP. IV.]
SANGUINEOUS FUNCTION.
209
benign and erosive, in the following words:  " sometimes  it trails
along, the part healing that was 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 fi.  Celsus then passes  on  to  describe  his second
species, which answers to the character and almost to the words of
erythema grangrcenosum, 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 QXvxrxnxi 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 q>hvx.rxtmi, 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;"*
Avhich Lucretius has thus forcibly rendered.

         Et simul ulceribus quasi inusti'-, omne rubeie
         Corpus, ut est, per membra sacer quoin 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 holy  fire.

It is perfectly clear,  then, I  think, that the ignis saceb 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.  ir.                   27 
210                   H/EMATICA.              [CL. IH.-OR. H-

a 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 habit- ; and, under this form, has been occasionally denomi-
nated by authors ervthema mercuriale,  and hydrargyria, as we shall
have occasion to notice still further when treating of syphilis.
                        SPECIES  V.

                ERYTHEMA  PERNIO.

                          ehtlfclatn.

INFLAMMATION OF A CRIMSON COLOUR, SUFFUSED WITH BLUE ; OBSTINATELY
     ITCHING J CHIEFLY AFFECTING THE EXTREMITIES DURING WINTER.

This species offers us the two following varieties:

x Simplex.               The cuticle remaining unbroken.
  Simple Chilblain.
/3 Exulceratus.            Accompanied with ulceration.
  Kibe.
  The extremities principally affected by the chilblain  are  the
hands and feet; but in very cold climates the nose, ears, and lips are
affected 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 of fire.

  That the pernio or chilblain belongs to the genus  erythema is
perfectly obvious, not only from its symptoms, but from the character
of 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.             21 I

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.

              iFeet   TSvonimi of the .Skut

COLOUR OF  THE INFLAMED PART BRIGHT  RED ; CUTICLE ERODED ;  THE
       EXPOSED SKIN OOZING A LIMPID AND ACRIMONIOUS FLUID.

The fret or erosion which frequently takes place in different  part?
of the skin from an acrid secretion of the exhalents or sebaceous
glands, and particularly behind the ears, about the groins, and around
the anus, is usually accompanied with erythematic 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  consequence 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
imbibed by dry and  scorched rags applied to the  part, or starch
frequently dusted over it.  But the irritability is here best suhdueil 
212
HiEMATICA.
[CL.  III.-OR. II.
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.
                     GKNITS  VII.

                      EMPRESMA.

                 Sffsceeal Knttammatfon

DERANGED FUNCTION OF A VISCERAL ORGAN, MEMBRANOUS OR PARENCHY-
  MATOUS ; WITH LOCAL  PAIN; FEVER MOSTLY  A CAUMA;  INFLAMMATION
  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  ttpai,  which is  itself  a ramification from tu,  and
imports,  not merely action, " putting or going forth,"  which is the
strict and simple  meaning of  w, 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 confusion,
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 ofEMp^ESMA, 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.              213

  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 tfie 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 life 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 eases, is much
 quicker and smaller than when inflammation 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 Us very beginning, it ha*  the same  effect upon the constitution a*
 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                    HjEMATICA.            [cl. ih.-or. II.

 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
blood  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  part, 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.

               XnttamwattoH ot  tfie iSratu.

PAIN  IN THE  HEAD ;  AVERSION  TO  LIGHT ;  FACE  MORE OR LESS FLUSHED J
                            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.
Fiom 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. VII.-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 membranous and muscular inflamma-
tion, before the access 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 disease 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 :—

x 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 of   regularly flushed ;  pulse irregu-
     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
HJEMATICA.
[CL. III.-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; redness 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, 1 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-
 gei, 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 alone.  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  ommonly se:)tfd, in the s-ibsmnce of the brain itself than
 in its  membranes, they have all been dissatisfied with their respec- 
GE. V1I.-SP. I.]
SANGUINEOUS FUNCTION.
217
tive 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 ano-
malous.
  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  douominated acute or
internal hydrocephalus as*a variety of cephalitis, requires to heexa-
mined  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  his 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 befow puberty, first  with lassitude, feverishness, (febriculd,)
  vo».  u.             28 
218
HJEMATICA.          [CL. IH.-OR.  II.
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 symptoms 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  gteat 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-
drocephalic;! : and more simply under that of febris hydrocephalica,
in Professor Daniel's edition of Sauvages; whilst 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 hrain,—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 th,«■ 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,! 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.  Hoe°s. Diss.Obseiv. Medico-chir. Jen. 1762.
t Majanet, Jowrn. de Med. Tom. xli. 65.  Id. Tom. xx. 553. 
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 thebasilary 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 progress
of  the disease  breathed sonorously but without stertor.t  Whether
in the  case of effusion between the  membranes, the fluid be confin-
ed, where the disease commences in the meninges, to the space  be-
tween  the dura-mater and the arachnoid tunic, and  where it  com-
mences in a  contiguous part of the  brain, to that between the arach-
noid 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 considerar
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 mama, 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. Synipt. CI. xi. Ord. in. Gen. xii. 
220
HiEMATICA.
[CL. III.-OR. II.
attack, and the violence of the fever;  added to which there is in
phrensy, for the mo<t part though not always, a hurry and contusion
of the mental powers, a weakness an I unsteadiness of mind, which is
rarely or  perhaps never to be met with  in genuine mania. It some-
times, however, runs into mania, of which Stoll has  given a singu-
lar 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 ;  inebriation
and  especially  from spirits ; exposure  of the*naked head  to the
ravs of a vertical sun ; violent passions of the mind ; obstructed men-
struation ; 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 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  incon-
venience.
   1 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-
 * Bat Med. Sect. in. p. 179.
+ n«g« Nouo-w, 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.  1 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
ev acuated.  At this time the pain in the head was intense, with an
intolerable acuteness of hearing and sight, insomuch that the slight-
est  ii.4-ht 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
pounded 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 sev-
eral 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, 
222                      HiEMATICA.           [CL. I1I.-0R. H.

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 it is 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  symptom 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  progress 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 alrea-
dy adverted. 
GE. V1I.-SP.  I.]
SANGUINEOUS FUNCTION.
223
  The first symptoms are unquestipnably 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  examinations 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
for 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 la-
bouring 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 cupping
or leeches: the head should be shaven, and napkins dipped in ice wa-
ter, 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 than in- 
224
ILEMATICA.
[CL. III. OR. 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 wav, 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-full of blood only was taken away in this manner.
   Mercury employed both  externally and internally, in a quantity
sufficient to excite a ptyalism, has also been used  in  many instances
with great success,  both among adults and infants, but  particularly
among the latter.  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 of 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 sub-
jected  to the mercurial  plan of calomel  and  inunction.  In forty-
eight hours a ptyalism was excited, the symptoms  abated, and  the
child recovered.!
   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.

                         3Sar=aefte.

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     0
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.
t Id. vi. p. 221. 
GE.VII.-SP.H.]      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,t 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, aflecting 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, op-
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.


                          SWumpn.

PAINFUL UNSUPPURATIVE TUMOUR OF THE  PAROTID GLANDS, OFTEN  EX-
   TENDING TO  THE MAXILLARY :  CONSPICUOUS EXTERNALLY ;  OFTEN AC-
   COMPANIED  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.
  t Fabric. Hildan. Cent. in. Obs. 4.           m
  X Stalpart Van der Wiel. Magef. Journ. de Med. Tom. lxiv. Moehring, Obs
21.  SaiTiinl. Medinischen Wahrnehmungen, B. vm. p. 37.
  j Vol. v. Art. xvi. p. 212.
  || Mat. Med. Vol. n. p. 436. 442.
  vol. n.               29 
226
HiEMATICA.
[CL. HI.-OR. II.
fatal phlegmon, which we have  already noticed under the name of
phlegmone parotidea.  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 blanks.
  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 mamma? 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 tumour 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. VII.-SP. IV.]     9ANGUINE0US FUNCTION.              227


                        SPECIES  IV.

           EMPRESMA  PARISTHMITIS.

                          (kttfnsg.

REDNESS AND  SWELLING  OF THE FAUCES ;  WITH PAINFUL AND IMPEDED
                          DEGLUTITION.

This is the squinsy, or squinancy of our old writers;  the cynanche,
or angina of medical books.  Paristhmia from?r«p* and to-6/A.os, 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 dessertation to the No-
sology.  Aetius attempted to justify cynanche, butCaelius Aurelianus,
and Paulus, used synanche after Celsus.  The Latins employed angina
in the same extent as Hippocrates did paristhmia; quinsy is used in
a parallel  latitude  among ourselves.  Sauvages  conjectures, and
there  is some ground for the opinion,  that the  synanche of the
Greeks was the  common  quinsy of the present day,  the parithmitis
tonsilaris of the system before us; their parasynanche, the quinsy of
the pharj nx, 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 x>f the  mucous mem-
   Common Quinsy.                 brane of the  fauces, and es-
   Inflammatory sore throat.          pecially  of the  tonsils ;  red-
                                   ness florid; fever a cauma.
o 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.
y Pharyngea.                     Redness florid, and especially 
228
HjEMATICA.
[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 quinsy, the  swallowing is,  for the
most part,  srreatlv impeded:  and the speech, and sometimes even
the respiration rendered higfhly 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 is  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 w'thin 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 fiave
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-
tern -illy, 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 :t 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

   * Schenrk. Lib. 11. Obs. 36.
   t Ballonius, i. p. 182. Fernire, Journ. de Med. Tom. lxii.
   X Fienus, Chir. Tract, iv. v. c. 1.  Musgrave, Phil. Trans. N. 258. 
GE. Vlf.-SP. IV.]   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 commonly
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 here of 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 -r or with a strong de-
* Pract. of Phys. Part i. Book in. Ch. iv. Sect. dcli. 
230
HiEMATICA.
[CL. II1.-OR. II.
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,t 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 hydropi-
per, Linn.) better known in the pharmacopaeias 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.
t Collin. Med. Comment, n. 27.  Stephen, Med. Comment. Edin. v.
X Rumsey, Lond. Med. Journ. x.—Medicus, Beobachtungen u. 505. 
«E. VII.-SP. V.]    SANGUINEOUS FUNCTION.               231
      w                SPECIES  V.


            EMPRESMA LARYNGITIS.

              Knflammatfon of the &argnj:.

pain  about the larynx ;» epiglottis swollen and erect; breathing
  shrill and suffocative ; great  anxiety ;  deglutition  impeded ;
  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 noticed
by Hippocrates.  It is minutely  and accurately detailed by Dr.
Home,  in his Principia; and is the subject of several excellent pa-
pers in the Transactions of the Medico-C'hirurgical 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 accompanied  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 existence 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.
t Obs. 29. ex Trincavellio, Lib. n. 
 232                      HiEMATlCA.           [CL. I1I.-0R. II.

 diseases differ, moreover, in their proximate causes as considerably
 as in their symptoms.  Laryngitis  consists in a suppurativ&nfian\-
 mation 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 take off 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 wriiers advise the
 application of a blister, and  the use of relaxant inhalatfons.  But, in
 preference to both, 1 would  recommend gargles of ice-water acidu-
 lated, 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, must be left to the judgment of the surgeon
 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  were 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-eighth 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. V1I.-SP. VI.]    SANGUINEOUS FUNCTION.               233
                        SPECIES  VI.


             EMPRESMA  BRONCHITIS.

                           (Croup.

breathing  permanently  laborious and suffocative ;  SHORT,  DRV
 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.
fl  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 infla/nmation  that spreads  through  different parts or even
the whole range of the windpipe, from the larynx  to the  minutest
ramifications of the  bronchia?.  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  spe-
cies 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 lar-
ger parts of the tube ; during which a peculiar effusion is secreted
that readily assumes a membranous form,  and lines, not  only the
trachea above its devarication, but also its minutest branches, though
  voh. n.                    30 
234
II.EMATICA.
[CL. I1I.-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-
sitv, 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 org m;
but this is unquestionably  a mistake.  There are few practitioners,
perhaps, of accurate observation, who  have not found it discharg-
ed at times from  the intestinal canal; of which I have already given
examples under diarrhea tubularis;  in  which, as in croup,  there is
an inflammatory  affection  of the  morbid organ,  nnd 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 day 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.j
  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 Angina polyposa. Auctore Christ. Fred. Michaelis. 12mo. Argentor. 1779.
+ De Suftbcatione 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 equal-
ly in midland regions and on the coast: but perhaps more frequent-
ly in low, marshy grounds, than in drier uplands.  There is no un-
equivocal instance of its being contagious, though it seems to have
been occasionally epidemic.
   It commences usually with a slight cough, hoarseness, 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 it is 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 represents 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 men>
"' Pract. of Phys. rccxxiv. 
236
H/EMATICA.           [CL. 11I.-OR.  II.
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 tends 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.
  'I he 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 membranous 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 is8 excreted.
V.ery 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,! 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 he 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.
t Fieliz.  Richter's Chir. Bibl. vin. B. p. 531.
X Fieliz,  1. c.
$ Inquiry into the nature, &c. of the Croup.
|| De Angina polyposa, &c. ut supra. 
GE. VII.-SP. VI.]      SANGUINEOUS  FUNCTION.             237

  Under the genus laryngismus belonging to the second order of the
preceding class, 1 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 any
 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 inosculated 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 tip  from his  lungs in a  fit  of coughing,
 yxXaxrJisx, " white milky  concretions;" and at  length before  he
 died o/ev m jmv|)j$ ftvtcqrx, \vnoTwvtx, tevxa QXtyftxrt Trt^n^oftnx,  " 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.1
 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. vn. Sect. xli.
+ Vol. i. Art. xvi. 
238
ILEMATICA.
[cl. iii.-or- n.
with  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 pul^e beat from a
hundred to a hundred  and twenty  strokes  in  a  minute for  the
ensuing twelve days,  at the close of which period,  she  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
oppression  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, a» 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 lamina?, which are easily separated from each
other, and  are manifestly  of a texture-less  and less firm as vou
approach  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 lamella? 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-glove.
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 setons or caustics.
                       SPECIES  VII.

            EMPRESMA PNEUMONITIS.

                      iScrijmcumotts.

inflammation of the  lungs ;  obtuse pain in the chest ; constant
  difficulty of  respiration, alieviated  by an erect  position ;
  timid, purple face, or lips ; 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, employed
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.
£ Maligna.                   Fever a synochus or typhus; the
  Malignant Peripneumony.       debility extreme from an early
                                period.  Often epidemic.
y 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 «ide  to the other; and, when  the  lower part of the 
240                     HiEMATlCA.            [CL. III.-OR. II.
 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,! anQl 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 BaroniuslT and Bovillet,** as endemic.
  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 case^
 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.
+  De Caballis, Phoenom. Med.
f  Cleghorn. p. 262.
i  Stoll, Rat. Med. Part n. p. 376. Act. Nat. Cur. Vol. v. Obs. 124.
||  Epist. ad Haller. iv.

"^Pleuropneumonia Ann. 1633. Flaminiam infestante.  Fidi. 1536.
 * Mcmoire.- mr les Pleuropneumonies cpidemiques, p. 556. 
GE. VII.-SP. VII.]     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 uni'requently a flow of blood, apparently from the  mouths
of the  exhalents 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 far 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,  and 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
of 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
ami 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 will bear bleeding far
more reaJily 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.
                 ' Rat. Med. ill. 5:7.
vol.  n.                  :\l 
^42                     HJEMAT1CA.           [CI-  IH.-OR. »•

and assume  the  second of the varieties before us.  And  hence,
where there is any doubt upon the subject,  local bleeding  is to De
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 ot taking
off the  entony of the  arterial system.  One of the  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, 1 can recommend them when the disease has made a conside-
rable  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 exhalents of the lungs to an increased se-
cretion of mucus.  Blisters,  as is the common practise, 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. VII.]     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 subtervene, 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  mvlignant  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 writer-, 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 laboriousness 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 he 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 effecting 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 t^ied, 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  counte-
nance, are among the most favourable  diagnostics.
  * Pelargus, Medicinische Jalirgange I. i. p. 44.  Tissot. sur 1' Epidemie en J :i>
3aii!ic, ice.
  f Journ. de Med. Tom. xi.vi. p. 24. 
244
ILEMAT1CA.
[CL. III.-OR. II.
   The spurious or  bastard peripneumony is  usually allowed to of-
fer another variety of this disease ; and is described under the name
of peripneumonia notha by Boerhaave, Coze, and Sydenham.   It is,
in many  instances, little  more than a severe catarrhal  atlection of
the lungs, accompanied with great obstruction, occurring in habits
of a peculiar kind; and is hence denominated  by many authors
catarrhus suffocative   It is  characterized  by great  secretion and
expectoration, with a mild cauma ;  and is chiefly found in those of
advanced life, or 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 conside-
rable 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. VIII.]    SANGUINEOUS FUNCTION.             245


                       SPECIES VIII.

              EMPRESMA  PLEURITIS.

                         Pcurisg.

VCUTE 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 memurane 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 diffe-
rence 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.
a 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.
C 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 
 246                    hjEMatica.            [cl. iii.-or. u.

 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 intercostafor  other thoracic muscles alone, since the
 pain is confined 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 ie
 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  pleurisy 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 loss 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 gener-
 ally acceded to by practitioners of all ages and  all nations.  The
 only question which has  ever arisen upon the subject  being, wheth-
 er 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. VII.-SP. VIII.]      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  dvspncea, 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 preceeding.
   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 pleuritis, 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 paraph-
renias ; terms derived apparently from  the peripatetic philosophy,
which supposed the  seat of  the <ppw, or soul, to be  the  praecordia;
whence this region was denominated tym;;  while,  as Hippocrates
supposed its seat to  be in the brain, phrenitis, with a lamentable confu-
sion  of terms,  was, as we have already remarked, applied to an in-
flammation of  this  last organ, and continues to be  very generally so
applied in the  present day.
  It is in the last variety that the head is most commonly affected ;
probably  from the general  sympathy  which <he diaphragm holds
with the  lungs and the stomach, and the  close community of action
between both  these organs and the brain.  The  breathing is  here
peculiarly distressing and  anxious, the diaphragm being the muscle
chiefly concerned in  respiration, which now takes place without its
aid.   The hypochondria are  drawn inwards and kept at rest as much
as possible ; the patient is tormented with  hiccough and sickness;
and there is a  peculiar tendency to  spasmodic action ;  whence the
angles of the  mouth  are often involuntarily retracted; there is a
sardonic  laugh on the countenance, a sense of lightness  like the
stricture of a cord  at the  praecordia;  and convulsions wander  from
one part of the system to  another.   The treatment should  be  as in
the preceding varieties. 
248                    BLEMATICA.             [CL. III.-OR. II.


                        SPECIES  IX.

               EMPRESMA CARDITIS.

               Xnflammatfon  oi  the fltart.

PAIN IN THE REGION  OF THE  HEART, OFTEN PUNGENT ; ANXIETY ;  PAL-
                   PITATION ; IRREGULAR  PULSE.

The svmptoms in the definition sufficiently distinguish this species
from the preceding   At the same time it  must be  acknowledged,
that carditis, like pleuritis, has many signs in common with pneu-
monitis ; which  may readily be  conceived from the vicinity  and
close  connexion of  the thoracic viscera  with each  other, and par-
ticularly from  the very strong sympathy with which, as already ob-
served, they  co-operate.  Dr.  Cullen  affirms, indeed, that  he has
often met with cases of carditis evincing no other symptoms  that
those of pneumonitis.   It is probably on the same account that Lin-
neus has taken no notice of carditis in  his nosological  arrangement.
Vogel's definition is founded  altogether upon this view, " Cordis in-
flammatio fere ut in peripneumonia."  I have hence been at some
pains to draw  a line of distinction;  and I think it may be found in
the symptoms now  delivered as the specific character of the dis-
ease.   We  may add to these symptoms, that there is great difficulty
of breathing, generally some degree of cough, and a perpetual ten-
dency to fainting; and that if deliquium take place,  and  the patient
do not  soon recover from it,  it proves fatal.
   We are not  in possession of any signs by which an  inflammation
of the  pericardium can be distinguished from that of the substance
of the heart;  and hence  we cannot make a distinct species  of  the
latter.   Vogel and a  few other  writers have  attempted it, but the
boundary has not been clearly drawn, and has never been of use.
  Upon dissection, adhesions have been occasionally  found to  a very
considerable extent between  the heart and pericardium, even where
little inconvenience had been felt during life.  From which we may
collect that  the extent of motion  of these two parts on  each other
is not very great.   A purulent  kind of fluid has  at times also been
detected on the outer surface of the heart, without the slightest ap-
pearance of ulceration either of the  heart or pericardium;  and as
the same sort of secretion has often been  traced,  without ulceration
in  other  cavities, Mr. Hewson, as we have already  seen, first sus-
pected, and  Mr.  Hunter afterwards  endeavoured to establish, that
this fluid is  nothing more than  coagulable lymph thrown forth from
the vasa vasorum, but changed in its  nature in consequence of  pas-
sing through vessels in a state of inflammatory action.  And  it wa9
this discovery, and the hint  thus founded upon it, that gave  rise to
the doctrine now so generally admitted, and apparently so well sus- 
GE. V1I.-SP. IX.]
SANGUINEOUS  FUNCTION.
249
tained, of a distinct secretion of pus, in many cases without ulcera-
tion.
  The causes of carditis are often obscure : when we can trace them,
they  are for the most  part those of pneumonitis; and the mode of
treatment needs not essentially vary.
                        SPECIES X.

            EMPRESMA PERITONITIS.


           Xuflammattou oC  the peritoneum.

PAIN  AND TENDERNESS  OF THE ABDOMEN,  ESPECIALLY IN AN  ERECT POS-
  TURE ;  WITH LITTLE AFFECTION OF THE SUBJACENT VISCERA, OR AB-
  DOMINAL WALLS.

The inflammation may be seated in the peritoneal membrane lining
the cavity of the abdomen, or in its extension  to  the  mesentery
or omentum.   And hence Dr. Cullen has noticed the three follow-
ing varieties:—

x Propria.                     The inflammation taking  the ge-
  Proper inflammation of the pe-  neral range of the peritoneum;
     ritoneum.                    pain  extreme, often pungent,
                                 with little  or no relief from
                                 stools.
Q Omentalis.                    With a more sensible swelling in
  Inflammation of the omentum.    the region of the omentum.
y Mesenterica.                  Pain deeper seated,  and more im-
  Mesenteric inflammation.        mediately in the   mesenteric
                                 region: external tenderness less
                                 than  in  the preceding  varie-
                                 ties.

  It is singular that Dr. Cullen, after distinctly  characterising  this
species in his Nosology, and following it up into three subdivisions,
each of which with him forms a  separate species, as the general
disease does a genus,  should take no other notice of the entire com-
plaint in any form, except what is expressed in the  following laco-
nic remark: " Among the inflammations of the  abdominal region,  I
have given a place in our Nosology to the peritonitis;  compre-
hending under that title, not  only  the inflammations affecting  the
peritoneum lining the cavity of the abdomen, but also those affect-
ing the extensions of this membrane in the omentum and mesente-
ry.   It is not, however, proposed to treat of them here,  because  it
is very difficult to say by what symptoms they  are  always to be
  VOL.  II.                 32 
250
H&M-AT1CA.
[CL. lrt.-OR. ErS«
known ; and further, because, when known, they do not require any
remedies besides those of inflammation in general.
  This remark is by far too sweeping.   If the diseases referred  to
Ja*ve w specific symptoms bv which they can be known, they have
no  more claim to be  admitted  into a > v&tem of symptomatic no-
sology 1iaa into a- treatise of practice.   Dr. Cullen is right m as-
signing- tneara' place in the former; and he  is,  therefore, necessa-
rily wrong in banishing them from the  latter;  and the moie so,  as
the treatment ought in some degree to  vary  from that of enteritis,
to which his general observation seems chiefly to refer.
  The true peritonitis occurs, as we have  already observed,  as a*
symptom in puerperal fever; and as we have treated of it at some
kmgti?  Ji-.der that disease, it is the less necessary to  be minute  in
our at/s-v^  at present.   Puerperal fever,  indeed, is sometimes,
though no? qafte ctorrectly,  made a variety of peritonitis : for  it is
a disease of a peculiar kind, produced  by peculiar causes,  and is
iiuly connected with  peritonitis  as the  latter enters as a symptom'
i'.llo its general character.  In what light Dr. Cullen regarded puer-
peral fever does not appear from his writings, since, common as the
complaint is, it does not occur in any of them; which  is the more
e^rrarordinary as his System of Nosology, Which is not comprehen-
sive enough to  include many diseases,  might easily have found a
place for this.
  In the specific definition it is stated, that peritonitis  occurs "  with'
little affection of the subjacent viscera  or abdominal walls."  In ef-
fect if often  happens that these are not at all influenced, and when-
ever they are,, fit is  only  secondarily.   " If  the  peritoneum,"  says
Mr. Hunter, " which fines  the cavity of the abdomen, inflames, its
inflammation does not affect the parietes of the abdomen ; or if the
peritoneum covering any of the viscera is inflamed, it does not af-
icctthc viscera.  Thus, the  peritoneum shall be universally inflamed
as in puerperal fever, yet  the parietes of the  abdomen, and the
proper"coafs of the intestines, shall not be  affected:  on the other"
hand, if the parietes  of the abdomen, or the proper coats of the in-
testines are inflamed,, the peritoneum shall not be affected."*
  We hence perceive another proof that the membranous tunics  of
the  different viscera  do not hold an  equal intimacy of action  in
every instance.  And it would be  interesting to  follow up the dis-
crepancy, and draw  a scale  of their readiness or inaptitude to sym-
pathise with  the viscera  which  they  cover.  The membranes  of
the  inarn, as we have already seen, are so  peculiarly disposed  to
partake of the inflammatory action of the parenchyma, as to render
solitary inflammation e-f the one or of  the other a rare occurrence.
In the lungs  the play of relationship is far less  conspicuous and  in
the  viscera of the abdomen it rarely takes  place.  And it is owing
to this  circumstance that we are able so generally to draw the  line
between inflammation of the peritoneum and of  the intestines, from
the  pain being much more superficial in the former than in the lat-
* On Blood, ice. p. 244. 
-yiE. Vn.-SP. X.]       SANGUINEOUS  FUNCTION.            255

ter case, and, in many instances, not accompanied with  sickness 01
•any other disturbance of the alvine canal.
   The causes are those of inflammation in general, as fold, exter-
nal injuries, and a morbid transfer-of action ; ami, in <a iev,- cmes.
sympathy with the adjoining organs, as in puerperal fever.
   The treatment is, in like -mtinner, that of inflammation in general,
particularly that of e. enteritis, to  which the  reader's attention i*
especially directed.  Bleeding, "both  general and local, should be
carried into effect ccpieusly and with all  possible speed..;  lust purg-
ing, though at all  times of service in inflammatory  affections, is
..'.ess imperiously demanded than in  inflammation of the intestines.
Warm stimulant fomentations may be advantageously ajepL'-tfiJjc  the
abdomen, and blisters in succession : but. after *. very free *se of
beeches, I have found more benefit in applying a large  folded  flan-
nel wrung out in'?.»'-ri;J.e hot water, or v/ater impregnated with aro-
rmatic herbs over the whole of the abdomen, and letting it remain
■(.here for many hours or till dry, wrapped  over with a  broad cilice
>or flannel swathe that surrounds, the entire body.  All we .r::n.possi-
bly aim  at, in applications of this kind, is a continuation  of moist
 warmth, as in a common poultice ; and this is-obtained more easily,
 a.id with infinitely less fatigue to the patient or danger of giving
 him cold, than in the ordinary  way of applying-fomentations. When
 the bowels have been well opened, opiates  may be given with free-
 dom, and-especially jr -ucisoe-w-ith ipecacuan-or a-nU.rxiQi.u3.ts £o de-
 termine fo the snrfi.ee.
   When ■'the inflammation commences  oris  seated  in the omextcm
 or ephloo.v, the pain is more limited,  and points rather towards the
 superior and middle region of the abdomen, a little above the navel;
 though it sometimes inclines to the light or  left hypochondrium.
 The peritoneum itself does not readily pass into a secretion of ge-
nuine pus; «and still less  so the omentum, which, where ulceration
 takes place, generally evinces  a foul and si.niotis-secreri.it/tL   .Salva-
 ges gives a striking example of this in a woman, whe wiK/f.t'first at-
 tacked with  an acute lancinating pain hi the umbilical  region;  and
 had a tumor formed towards the  right hypochondrium about  the
 size of a mans fist, which  by <legrees occupied the whole abdomen.
 By an  application of emollient cataplasms, the pain  and general
 swelling were diminished in the course of three days;  but a fluctu-
 ation in the abdomen was next detected, like that of an ascites: in
 consequence of which, altochar was introduced into both sides of the
 abdomen, and a putrid ichorous fluid was discharged, wuich induced
 the operator to enlarge the opening.;  when sloughs of the  omentum
 already separated came away with an intolerable  stench,  and  with
 r.bout two pounds of  what Sauvages calls ichorous water.   But the
 skill of  the surgeon was overpovrered by the disease, and the pa-
tient fell a victim to  it.*
   life mesentery  has but a small degree of sensibility, and hence.
* Noiol. Med. Class iu. Ord. HI. xvi. 
252
HjEMATICA.
[CL. IH.-OR. II.
as well as from the greater depth of the seat of the disease, mesen-
teric  inflammation is only discoverable by pressure.   If the  affec-
tion be strictly mesenteric, the symptoms are mild and gentle;  but
this is a rare case, and chiefly occurs when the  glands are obstruct-
ed, and any accidental irritation is applied to them.   Most common-
ly it is catenated with inflammation of the  spleen, liver,  or  intes-
tines.
  The medical treatment will be  the same as in hepatitis, or sple-
nitis : though bleeding, in general, effects but little benefit.
                       SPECIES XI.

              EMPRESMA GASTRITIS.


              Inflammation ot tlie Stomach.

BURNING PAIN AT THE  PIT OF THE  STOMACH, INCREASED ON SWALLOWING:
  REJECTION  OF EVERY THING ; HICCOUGH ;  OPPRESSION AND  DEJECTION
  OF MIND J  FEVER A SYNOCHUS.

Inflammation of the stomach may be either of the adhesive or  the
erythematic character; and the species hence offers us two varie-
ties with considerably different symptoms;  which is chiefly, indeed,
the result of the peculiar nature of the fever that accompanies  this
inflammation, already stated to be a synochus, or fever commencing
with caumatic, but  terminafjag in typhous  symptoms.   For  this
kind of fever it is  not  difficult to account.   We have  often  had
occasion to state  that the stomach is  the  common centre  of sym-
pathy ; it is  also an  organ of  acute sensibility ; and it is hence  im-
possible for it to suffer from inflammatory action  without suffering
severely, and without extending its affection very widely.  -The na-
tural consequence is, that there  must be great, and general, and sud-
den debility, and the fever, though commencing with excess of ac-
tion, may soon lead  to total atony, and fatal consequences.

x Adhaesiva.                    The pain very acute ;  the fever
  Adhesive  inflammation of the    violent.
    stomach.
C Erythematica.                With an  erythematous  blush  ex-
  Erythematic inflammation  of    tending to, and visible in  the
    the stomach.                  fauces;  pain more  moderate;
                             tP  fever  less violent;   pulse  low
                                 and quick.

  Dr.  Cullen seems to  have been  the first writer that distinctly
pointed out the nature of these  two varieties, which  he  has unne-
cessarily advanced to  the rank of species, and later writers have 
GE. VII.-SP. XI.]      SANGUINEOUS FUNCTION.             253

justified the expediency of a  distinction  This  distinction, as al-
ready remarked, is produced by the nature of the accompanying fe-
ver ; and consequently, in a considerable degree, by the nature  of
the constitution in which the disease occurs.  The fever is perhaps
in every instance a synochus, the cause of which we have just stat-
ed ; but, while in  a firm and  robust habit the febrile  course has,
comparatively,  but little tendency to pass from the entonic action
with which it commences, into a dangerous languor  and atony;  in
relaxed and irritable habits it is apt to run into this stage  almost
from the first, and the synochus degenerates rapidly into a typhoid
character.
   In both varieties  the causes are alike;  as  external  or internal
cold suddenly applied in a heated state  of  the stomach, acrid sub-
stances, or excess in eating.   The acrid substances chiefly recorded
are jalap and other drastic purgatives  taken in  excess; oil  of vi-
triol ;  corrosive sublimate ; and very large doses of nitre, or quan-
tities swallowed by mistake, as an ounce, or an ounce and a half, of
both which we have an example in the Journal  de  Medicine.*  It
is also^aid to have sometimes been produced by  a severe paroxysm
of cololithus ;t and occasionally to have followed upon trichosis plica,
 the matted hair of Poland.|  A sudden chill by swallowing cold wa-
 ter  or some  other fluid  on  a heated  frame has  been a frequent
 cause : as  has also repelled gout, indigestible  food,  and especially
 ardent spirits drunk profusely.
   The symptoms are  sufficiently detailed in the specific definition.
 Several of them are those of cardialgia; but  in  the latter there is
neither fever nor vomiting.   From the  close sympathy of the sto-
mach  with other organs, the disease has  sometimes  been  accompa-
nied with delirium, and in a few instances with hydrophobia. Where
the inflammation is violent it destroys in a few days.   If no fatal
symptom occur within the first week it terminates for the most part
favourably.  Shiverings and a remission of pain,  are, as usual, marks
of suppuration.
   Of the adhesive variety Mr. Cruikshank  has given a good  illus-
 tration in the case of a young lady who died after two  or three
 days illness, before which she  had  been in perfect health.  " I was
 called in," says he, u but she was dead  before 1  got to the house.
 From her  history  I was at a loss to account for  her death : but  on
 opening the abdomen a day or two after, 1 found the contents of the
 stomach in that cavity ; that they had produced peritoneal inflam-
 mation, and killed.  On examining the stomach,  1 found a hole in it
 large  enough to admit the end of my finger.  This hole had been
 formed by absorption  of part of the substance of the stomach from
 scrophulous ulceration: its edges  had  adhered  by inflammation to
  * Lnflize, Tom. lxxi.  Souville, Tom. lxxiii.
  t Kaltschmied, Pr. de jEgro inflammatione ventriculi demoituo cnlculis, to-
Jen. 1757.
  X De J;i Fontaine, Chirure. Med. 
*254
lO.^lATlCA.
[CL. I1I.-OR. II.
the under surface of Ihe small lobe  of the  liver.  This inflamma-
tion was evidently raised by the powers of the body to prevent the
accident which happened: and  if no  violent  vomiting  had taken
place, and torn this adhesion at this particular time, she might have
lived for years notwithstanding the ulcer.1"*
  Gastritis has often been represented in a  more  dangerous light
than it deserves to be : for in neither variety is it frequently attend-
ed with fatal effects under judicious treatment,  in the true adhe-
sive form copious and repeated venesections have been very gene-
rally recommended, and have often been found of the highest advan-
tage, particularly in robust and  vigorous habits.   To be, however,
of any decided avail, this plan  of treatment  should be commenced
early; for the fever is so apt to pass into a typhoid form, that, aftei
the first two or three days, too  much  inroad will generally have
been made upon the constitutional strength to allow of the use of
the lancet.   If acrid poisons, ur excess of eating, be the cause, an
emetic should be administered; but otherwise this, as  well as all
other stimulants, should be avoided.  Gentle  cooling laxajjves. a
blister applied to the pit of the stomach, mild  nutritive drinks, nu-
tritious injections, and, if the pain or sickness be extreme, doses of
a drachm of  the syrup of white poppies,  and perhaps about five
grains of nitre in an emulsion of gum arabic or spermaceti, will ge-
nerally be found the most successful plan.   It is, however, extreme-
ly difficult to get any medicine to remain on the stomach ; and hence
the best  form is that of pills.   If suppuration should follow, and the
abscess buret, a milk diet with the mildest food, and in small quan-
tities at a time, is the only plan to fee pursued.  If a gangrene take
place, all further exertion will be in vain : and we may determine
its presence by a sudden cessation of pain, coldness about the pra>
cordia, and languid or intermitting pulse, which are its sure attend-
ants.
  Upon  the  erythematic  variety,  the  following remarks of Mr.
Hunter are too valuable to be omitted : and they are the more va-
luable as they apply to disorders of other internal cavities  besides
the stomach.   " There is," says he, " an  inflammation  which at-
tacks internal canals which is  classed with  the erysipelatous; but
how far it is  the same I do not  know.  It is  certainly not  the sup-
purative.  Whatever it is, it may be considered in some of its effects
to be in direct opposition to the  adhesive and suppurative inflamma-
tions: for where the  adhesive most  readily  produces adhesions,
there the erysipelatous  does not, as  in the common cellular mem-
brane ; and where the adhesive seldom takes place, excepting from
extreme  violence,  there this inflammation  (if erysipelatous) has a
tendency to  produce adhesions, as in  canals or  outlets.  It  also op-
poses in some degree the suppurative,  in being backward in pro-
ducing suppuration even in those  places where  suppuration  most
\natoiny of the absorbent vessel?, p. )22, 
QE. tll.-SP. XI.]      SANGUINEOUS  FUNCTION.              255

readily takes place, such as canals and outlets ;  for there, as above
observed, it more  readily  throws  out  the  coagulating  lymph.
Whatever the inflammation may be,  it is certainly  attended  with
nearly the same  kind  of constitutional  affection.   The fever  in
both appears to be  the same, viz. accompanied with debility, lan-
guor, &,c."*
  The erythematic inflammation of the stomach comes on more in-
sidiously than the adhesive ; and is best characterised  by the inflam-
matory colour  of the fauces, for it usually spreads to  these,  and the
lowness and rapidity of the pulse.   The inflammation often  extends
through a great part of the alvine canal as well as the oesophagus;
and, after a subsidence of the sickness, produces diarrhoea, and mu-
cous discharges from the bowels.  It  is  sometimes so gradual and
tardy in its progress as to produce little  fever, or even local distur-
bance, for many days or  even weeks.  De Haent has repeatedly
referred to this sort of gastritis, and Hennings has described it more
at length.;};
  If this variety of gastritis be excited by  acrid or poisonous sub-
stances, a brisk emetic should be exhibited  with as much speed as
possible; and afterwards such antidote as the character of  the poi-
son may point  out: opposing acids to alkaline, and alkalines to acid
erosives,  and  the  most active stimulants to narcotics.  When the
cause is internal, mild, diluent, and cooling drinks are to  be em-
ployed freely.  The infusion of roses will often prove one of the
most serviceable medicines we  can  make  use  of; blisters should
be # applied  and repeated, and the bowels  kept  cool  by  laxative
clysters.
  Inflammation of the stomach is also found in the one or the other
of its varieties, as an occasional symptom in aphtha, measles, small-.
pox, and other  exanthems ; and perhaps, in repelled herpes,  scabies,
and similar eruptions.
 * On Blood, &c. p. 270.
 t Rat. Med. Part vi. ix. xiv. passim.
 X Buschvcibung der Kennzeichen und Kunder Entziindung des Magens and dei
Sadarrue. 
256
HjEMATICA.
[CL. III.-OR. II.
                        SPECIES  XII.

              EMPRESMA  ENTERITIS.

               Enflammatfon of the JJotoels.

GRIPING PAIN IN THE BELLY ; TENDERNESS,  AND VOMITING : FEVER A SY-
                            NOCHUS.

In inflammation of the stomach the pain  is seated higher, and is
rather burning than griping; this  last,  also,  has usually some de-
gree of hiccough, and great dejection of mind; neither of which be-
long to  inflammation of the intestines;  and it is by these  charac-
ters  that the two are to be distinguished from each  other.   Stoll
adds, that intestinal inflammation is also accompanied with a sup-
pression of urine : but we cannot rely upon this as a specific symp-
tom.
  Enteritis, like gastritis, exhibits two varieties:

x Adhaesiva.             Very acute, fever violent;  vomiting fre-
  Adhesive inflammation    quent; and costiveness obstinate.
     of the blood.
(8 Erythematica.         Pain more moderate; fever less  violent;
  Erythematic inflamma-    little vomiting, and diarrhoea instead of
     tion of the bowels.      costiveness.

  The causes  of both, as also of the accompanying fever  being a
synochus, may be understood from the remarks already offered upon
gastritis; the intestines partaking in a very considerable degree of
the character of the stomach.
  To the causes enumerated under gastritis may be added some na-
tural or accidental organic mischief in some part  or other of the in-
testinal canal, as ventral, inguinal, or other hernias, or introsuscep-
tions of various kinds; or infarctions from coprostasis, scybala,  or
enterolithus.   The plica polonica, or matted  hair, is said by De la
Fontaine to be a cause of this species, as  other writers affirm it to
be of gastritis.
  The progress of  the  first  variety  usually commences with a
sense of coldness or shivering, and an  uneasiness  in some part of
the belly, at first remitting or intermitting, but gradually acquiring
permanency, and rising into an acute pain.  The pain now spreads
over the whole abdomen, which is  tense  and tender to the touch,
though less so  than  in peritonitis; there  is  a great flatulency ac-
companied with occasional spasms that shoot backward to the loins
obstinate costiveness,  and unconquerable  vomiting.  The  pulse is
small, hard, and frequent, but has sometimes been soft:  the tongue
dry; thirst extreme;  urine  high-coloured, small in quantity, and 
 GE. VII.-SP. XII.]      SANGUINEOUS FUNCTION.             257

 discharged with difficulty; the breathing is laborious; and from the
 contraction of the abdominal muscles the patient is perpetually bend-
 ing forward.  If no beneficial change take place, all these symptoms
 become aggravated;  instead of feculent stools, there is an ineffec-
 tual straining,  with a  small  mucous discharge;  and with the in-
 crease  of the retching the feces burst through the valve  of the co-
 lon, and are  occasionally thrown up  from the stgmach.  At length
 the torture suddenly diminishes; and the  patient  appears to  have
 obtained relief: but his pulse intermits, his face grows pale, his ex-
 tremities  cold, convulsions succeed, and  he sinks in death.
   The general termination, therefore, when  unfortunate, is that of
 gangrene ; for it is rarely that  the  inflammation runs into a suppu-
 rative state.   If in the course of the  first  two, three, or even four
 days, a free feculent discharge can  be  procured  from the bowels,
 the vomiting and pains will gradually diminish, the pulse abate in
 quickness, and the patient be in the way of recovery.
   In treating this complaint, it is hence of the utmost importance to
 procure free evacuations, for the  cure depends almost entirely up-
 on our success  in this respect.  Yet the difficulty is  often  very
 great, and increased from  the tendency of the stomach to reject
 whatever medicines are introduced into it.  Most practitioners com-
 mence with  bleeding, which  they urge  very copiously, and repeat
 every six or eight hours,  according as  the pulse will bear the lan-
 cet.  The remarks we have made upon  this practice, under gastri-
 tis, will apply to the present species.   If the disease occur in a pa-
 tient of a hardy and vigorous habit, and particularly if we have an
 opportunity of employing venesection within the  first day or  two,
 we shall commonly find it of essential service : but if we do not suc-
 ceed, we shall assuredly hasten the stage  of gangrene, and  abbre-
 viate the term of remedial  operations.   And  hence, unless free
 bleeding can be employed early, and the constitution evinces  a to-
 lerable portion of vigour, there is no inflammation in which the lm-
 cet is less likely to be serviceable,  or may become more, mischie-
 vous.   To  local  bleeding,  even under  the  conditions  we  are
 now supposing, there is less objection ;  but we have less chance of
 benefit by it.than in peritonitis.
   Prom the first, therefore, we must attempt cathartics.   If the
 stomach will retain the milder, as castor oil, neutral salts, or senna,
 these are by far the most  advisable ; as our object  should be to di-
 minish instead of increasing the irritation  of the intestines.  But in
 the first species thi-  is rarely the ca*e ; and we must hence, without
 loss of time,  apply to those that are more acrid ;  as calomel in com-
 bination with the colocynth  pill; assisting their  operation  by in-
jections frequently repeated, and in as large quantity as the bowels
will retain them.
   It does  not necessarily follow that the irritation of these more
acrid purgatives .ml add to  the  inflammatory irritation; nor do  we
          * Tltpt Nou<rw, m. p. 491.
vol.  ii.              33 
258                    HAMAT1CA.             [«- I»'-°R' »•

always, or  even commonly, find any such  effect.   For, firstly, the
operation of the  two irritations is  very different;  and by exciting
the former we may even diminish or take  off the latter by a trans-
fer of action, in the same manner as we take off inflammation Irom
any other organ  by the  application  of a blister to some neighbour-
ing part.  Secondly, the direct effect of the cathartic  is to restore
a natural action,  the peristaltic action of the intestines, which it u
the direct effect of the inflammatory action  to oppose.  And thirdly,
we find, in fact, the beneficial influence of such a practice, not only
generally, but almost uniformly, and are incapable of accounting for
it upon any  other principle.
  Opiates would be desirable through the whole course of this dis-
ease, but that, in  their general intention, they add to the costiveness
if given alone, and retard the effect  of purgatives if given in conjunc-
tion with them.   Nevertheless, if,  after copious bleeding, the cos-
tiveness should be  intractable, and the flatulency  and spasmodic
pains very  distressing, it will be better to  trust for a  few hours to
two or three grains  of opium alone, and  withhold the purgative
plan for the present.   For the costiveness is chiefly  the  result of
spasm: and  if we succeed in allaying the spasmodic action, a cath-
artic will>answer  readily, and sometimes the bowels have been mov-
ed even by the tranquillity alone  which the opiate has produced.
  Fomentations and blisters to the  abdomen form a regular course
of the  therapeutic plan; and have,  no doubt, been occasionally ser-
viceable ; but, like  local bleeding,  they are less  so in the present
disease than in peritonitis.  And where fomentations are adviseable,
I prefer the epithem of a folded flannel wrung out in hot water, and
confined with a swathe, as already  recommended in peritoneal inflam-
mation, to all other fomentations whatever.
   Injections of warm water alone,  forcibly thrown  up the rectum
in as large  a quantity  as the  bowels can  be made  to contain, are
moreover often  found of essential  benefit, and are  generally to be
preferred to the  warm bath, which, by  adding to the debility, has
accelerated the approach of gangrene.
   After the bowels have  been freely emptied,  diaphoretics, and
especially combined with opiates, will be the best plan we can pur-
sue ; and, if the stomach become  quiescent, the patient should drink
freely of diluents.
   There is a singular  fact, noticed by Rhodius,* which sometimes
occurs in this disease, and  is peculiarly worthy of notice,  as sustain-
ing our  hopes  to the last: and it is this ;  that occasionally, in the
extreme moment of  a  seeming mortification, a sudden revolution
takes  place, and stools are evacuated ; and this, too, after the ex-
tremities have begun to grow cold, and an apparently deadly lan-
gour has overpowered the  frame.   In such case, we  must snatch the
patient from impending death by a free use of wine, and warm gene-
 rous cordials ; closely attending,  at the same time, to  a copious dis-
*Cent. n. Obs. 69. 
UE. VII.-SP. XII.]       SANGUINEOUS FUNCTION.             259

charge from the bowels, of which, with the liberal plan now recom-
mended,  we need not be afraid, and which we should be extremely
cautious  of checking by opiates.
  From the less threatening character of the symptoms, as they
show themselves in the  erythematic variety, this affection, as Roth-
boel has  well  observed, often exhibits a fallacious appearance, and
is misunderstood.*   And it  has hence been described on the conti-
nent, under the names of occult,  apyrectic and anodynet  enteritis.
Its real nature, however, is  as we have explained it  above.   It has
been well  ascertained that  the seat of this variety  is sometimes in
the external coat of the intestines ; and  it is said, by some writers,
that this is the most common seat.  It is not easy to determine up-
on this point:  nor always, at its commencement, whether the inflam-
mation be of the  one variety or  of the other, the modifying causes
being, in some constitutions, and  some seasons of the year and tem-
peraments  of the  atmosphere, so nicely balanced as to  leave the
course doubtful.  A case of this kind occurred to me in July, 1805,
in a healthy and active  young gentleman, thirteen years old.  The
abdomen was tense and  tender, the intestinal canal  painful through
the greater part of its extent; the pulse quick, and moderately full;
the skin  very  hot and  dry; the blood, when drawn  from the arm,
without any huffy coating ; the sickness incessant, with deep anxiety
and oppresion.  The greater part of these symptoms indicated the
adhesive variety;  but,  as the morbid signs increased, the stomach
evidently partook of the  affection, and shortly  afterwards  an ery-
thematic sloughing appeared in the throat on the fourth day from the
attack, evincing the real nature of the inflammation, and tha. it had
extended up the whole of the cesophagus.   On the sixth day the
patient died.
  Bleeding, which  was  reported  within about twelve hours, did not,
in this case, prove of any benefit ; though it  may be justified from
the mixed character of  the disease.  But in distinct  and simple ex-
amples of erythematic inflammation, it ought, unquestionably, to be
abstained from: and acids, and the milder tonics,  and  bitters, as infu-
sion of roses, cascarilla  bark, and cinchona, supply its place.
   1 have said that  enteritis is sometimes a result of  hernias.  It has
also, occasionally, been  produced  by a forcible protrusion of a part
of the  intestinal canal  through the anus ; of which a  singular in-
stance is given in the Medical Transactions, in a paper communica-
ted by Dr. Latham :J the  part of the prolapsed intestine was very
considerable, and the injury was  occasioned by the passage of the
wheel of a cart over the loins;  a  portion of the mesentery was pro-
truded with that of the gut; gangrene supervened to the inflamma-
tion, and the prolapsed  mesentery and intestine were cut off above
  *  Dissert, sistens Observations circa fnllaciam  signorniii  in inflammationibus
Abdominalibus. Hafn. 1776.
  t  Plocquet, Initia. Vol. v. 108.
  r  Vol. iv. Art. xxiv. 
2bO
HiEMATlCA.
[CL. III.-OR. II.
the line of gangrene ;  the latter to a length of not  less than fifty-
seven inches, mpasured by a string applied to the outward surface.
The patient,  who was a  boy, recovered ; had motions  regularly
from the truncated extremity of the remaining intestine ; and  was
able afterwards to walk'twelve or  fourteen  miles a-day.  He had
no powor, however, of restraining his motions, so as to postpone the
evacuation.
                       SPECIES XIII.

              EMPRESMA  HEPATITIS.

               inflammation  of the ILiotx.

TENSION, SORENESS, AND PAIN IN THE  REGION OF THE LIVER ; PAIN ABOUT
  THE .(IGHT SHOULDER; DIFFICULTY  OF LYING ON  THE LEFT SIDE J
  SHORT, DRY, COUGH.

Inflammation of  the  liver, which may in general be sufficiently
known by the above  characters, has also two varieties, dependent
upon its more rapid and violent, or more tardy and obscure march.

a Acuta.                      In which  the above  symptoms are
  Acute inflammation of the       clearly marked, and the  charac-
    liver.                        ter of the disease  is decisive.
C Chronica.                    In which the specific character is
  Chronic inflammation of the     obscure ; and  tohe existence of
    liver.                         the disease suspected  from a
                                  previous exposure to its causes,
                                  in connexion with an occasion-
                                  al  recurrence  of the pathog-
                                 nomic  symptoms, accompanied
                                  with a slight degree of fever.

  Sauvages, on the authority  of Amati, has given an  erysipelatous,
or, as it should rather be, an erythematic, variety of this disease, as
Lommius has, also, done of pneumonitis; but the parenchymatous
viscera do not seem to be subject to an inflammation of this descrip-
tion, as Dr. Cullen has correctly observed ; and as has been since con-
firmed by the remarks of Mr. Hunter which we have already  quoted.
  The acute variety commences  with the ordinary symptoms of
visceral inflammation; dullness, succeeded by heat, frequent pulse,
and a furred tongue: the bowels are irregular,  mostly costive; the
evacuations little tinged with  bile, the urine often saffron-coloured ;
the skin is dry, the thirst extreme, with occasional sickness.
  No physiologist has yet been able to explain  the  cause of the
pain so generally felt  in the right  shoulder.  It is  however sympa- 
 GE. VH.-SP. XIII.]      SANGUINEOUS  FUNCTION.           261

 thetic of other affections of the liver, as jaundice, or chololithus, as
 well as of hepatitis; and hence it should seem to be produced by
 almost any morbid excitement of this organ, whether from inflam-
 mation or the obstruction of gall-stones.   The cough, which is often
 very  distressing,  is easily accounted for from  the  vicinity of the
 diaphragfm to the  seat of disease,  and its sympathy with the  liver.
 The «ic!;neps of the stomach is from the same cause.
   The disease is sometimes accompanied with a jaundiced colour of
 the skin; and Sauvages and Sager  have  made such a colour a spe-
 cific symptom; but it is not always that the  bile regurgitates, and
 hence, such  an appearance ought not to be enumerated  among the
 pathognomic characters.
   Even where it exists it is not a distinct symptom of  hepatitis;
 for, to say nothing of proper"jaundice, the feces, as Dr. Latham has
 well observed, may be light-coloured, and the eyes, skin, and  urine
 peculiarly yellow, from the pressure of an indurated pancreas upon
 the bile ducts, and an obstruction  of their course.   And hence Dr.
 Latham imagines that an enlargement of the pancreas has sometimes
 been  mistaken for hepatitis, and a diseased ovarium still  more fre-
 quently.   On which account it demands  a very nice examination of
 the liver before we can speak with decision, and a pretty tolerable
 assurance to ourselves, that there is no enlargement  of either of
 the other organs.
   Dr. Saunders,  and  with some  plausibility,  suspects  the  acute
 variety is owing to an inflammatory state of the hepatic artery, and
 the chronic  to a  like state of the vena porta?.  Winslow ascribes
 both to an  inflamed state of the  ramifications of the  vena portae,
 which, in  his  opinion, constitute  the seat of the disease ;  while
 Cullen refers us to the hepatic  artery alone, and limits the seat of
 inflammation to its extremities.  Dr. Heberden  does not  incline to
 believe that the liver is  primarily  affected, but only influenced  by
 a phlogistic diathesis, or preceding inflammatory fever.
   If the  inflammation originate in  the membranes, the pain,  as in
 most  other cases  of membranous  affection, is peculiarly pungent,
 like that of a pleuritis; the fever is severe, the tension very consi-
 derable, the pulse  frequent, strong, and  hard ;  the urine  generally
 high  coloured.  When the  substance  of the  liver  is  primarily
 affected,  the  pain  and  pyrexy are  far less acute, and especially at
 first;  but they increase with the progress of the disease, or, in other
 words, as it  extends to the membranes, and not  only darts to the
 right  shoulder, but  sometimes shoots  as  far as  the throat and
 clavicle.
   Where the symptoms are most  severe,  and we have  reason to
 suspect that the disease is confined to the membranes, the duration
 is  often short, and the termination is in most cases that of resolution.
 But when less  active,  and  seated  in the parenchyma, it generally
 tends  to  suppuration;  and  if the  convex side of the liver be the
part  affected, a tumour is  visible  externally, the cough becomes
aggravated, and there is a difficulty pf breathing.  If adhesions 
262                      HEMATIC A.            [d- IH.-OK-  »'

hav  preceded the  suppuration, the pus points to the skin, and the
abbess opens on the surface ; but if it break internally it generally
p.\. ves fatal by inducing a hectic, though sometimes, in consequence
of fortunate adhesions, the abscess discharges itself into the hepatic
duct, and the pu* is  carried off by this channel.   It has, occasionally,
bv the same means,  made its way into  the  stomach and intestines,
wa.-:i- the  hUc;>ss has been very large.  In which case, however,
immcdialelv upon the bursting of the vomica, the patient throws off,
by sickness* or  by purging, a large mass of most offensive matter,
often filling the whole house with  its  noisome smell, and dies in a
few  hours? In like manner, the  pus  has  occasionally formed  an
empyema in the thorax ; and, in  a few instances, has been discharged
from the lungs.
  The disease sometimes also terminates in scirrhosity;  in which
case  the induration bears an extent in some -measure proportioned
to the range of the preceding  inflammation, and may often be felt
by applying the hand to the region of the organ.  This, however,
is a more frequent result of the second or chronic variety.
  In order to induce acute hepatitis, it is necessary that the organ of
the liver,  at the time  of  attack,  should be in a state  of at  least
moderate health and vigour; for  it is  in  this  condition only, that
inflammation running through its regular stages can take place, and
hence the  acute variety is found far more frequently in temperate,
than in intertropical  climates;  and in  the latter more frequently
among new comers, than among  those that have been long habituated
to the climate, and  whose  livers have been weakened  and relaxed
by the greater  heat of the sun :  " Among the men of the eighteenth
regiment," says Mr. Christie, who was stationed at Trincomale, and
had the  care of the entire garrison in 1798, " I found for  the first
six or eight months, the disease was much more  frequent, much
more violent in its symptoms, showed more tendency to suppuration,
and was more  sudden in its crisis, than with the company's Euro-
pean troops, who had been long in India, although the latter were
the most debauched.  Among the  natives hepatitis does not often
occur: out of  a thousand native troops, I did not, in the course of
three months, meet with more  than two cases of  liver-complaints,
which is  comparatively  a very  small  proportion."*  There  is,
however, a striking distinction  between the state of the bowels  as
affected  by this disease in hot and in temperate climates.  In the
latter it is rarely we  have any diarrhoea, and  often an  obstinate
costiveness, the evacuations being mostly  untinged with  bile.  In
the former, from the higher degree of irritation that prevails, and
the greater extent of its range,  a bilious flux is so frequent as to  be
almost a pathognomic symptom; and as the gorged vessels are apt
to give way from debility, this is sometimes intermixed with blood.
   In our own climate, bleeding  at the commencement of the disease
is generally found serviceable, and ought to be prescribed as speedy
* Letter to the Editor of the Medical and Physical Journal, May 1798. 
GE. VII.-SP. XIII.]      SANGUINEOUS  FUNCTION.           263

as possible ;  certainly before  the fifth day; and be repeated gene-
rally or locally, as the violence of the  symptoms may require and
the strength of the constitution allow.
  Free purging, with calomel and Epsom salts, should  immediately
follow ; and  mercury be at the same time introduced into the system
by the stomach, or by inunction, or by both.   From the costiveness
that usually  accompanies the disease it  is rarely necessary to unite
the mercury with opium ; though where it irritates the bowels, the
latter should unquestionably be given; as it should also to allay the
cough, when this symptom is very distressing and prevents sleep.
The  mercurial course, as recommended by Sir James M'Grigor,*
should be steadily  persevered in, not  only in hot climates  but  in
temperate, till a salutary change  has been effected, or salivation has
been freely excited.  It will  often be found,  however,  that the
patient will bear a long continuance of the mercurial plan without
any affection  of the  mouth ;  and will  gradually and insensibly toi-
prove under  it;  the soreness and tension   subsiding, the  cough
diminishing, the pulse becoming slower, and the heat and dryness of
the skin yielding to a pleasant moisture ; all which are prognostics
of a favourable issue.
   The application  of large blisters  over the  hypogastric region in
succession, is  recommended by most practitioners, but I have not
found them successful;  and have evidently derived more benefit
from fomentations, epithems, and the warm bath.
   Diaphoretics should certainly form a part of the curative process ;
and they combine admirably with the mercurial treatment; particu-
larly the antimonial  preparations.  Cooling,  diluent, and even
acidulated drinks should be taken copiously ; the diet consist chiefly
of  light  farinaceous  foods ; and  the chamber be well ventilated.
If from sudden shiverings, and remission of the quickened pulse, we
have  reason to believe suppuration has  taken place, columbo, the
mineral acids, and  above all  the bark, where  it can be retained,
should be given freely ; the cinchona, at least in the proportion  of
from half a  drachm to a drachm,  five or six  times a-day; and this
whether the  abscess be likely to burst externally or internally;
and if the former, the direction should be encouraged by maturating
cataplasms,  and the  abscess be  opened as  speedily  as  possible.
The  discharge  is sometimes  very considerable  in quantity, and
amounts to  several pints ;  the pus  is  occasionally found  pure, but
more generally intermixed with  coagulable  lymph or some  viscid,
yellow, fluid.   It is at times lodged in  different sacs, and hence
subsequent tumours ensue, and subsequent openings are necessary.!
   It is not alway-, however, even after suppuration has taken place,
that the abscess  mast necessarily  open in any direction ;  for the
following case will show that when we  have  full reason to believe
  * Medical Sketches, passim.
  t  Recueil d'Observations de Medicine des Hopitaux Militaires, &c. Art. par M.
Roucher, Tom. it. 4to. Paii<=. 
264
HEMATIC A.
[CL. IU.-OR. II-
such a result has occurred, the fluid may be carried off by absorp-
tion and the organ  be restored to a sound state.
  In the middle of last  February, I was requested to meet in consul-
tation  Mr. Patten, and several other medical practitioners ot h.gli
respectability, at Professor Gregory's of  Woolwich Common,  whose
son, eight years of age, had, for nearly three weeks, been labouring
under a considerable degree of fever, accompanied with a m x'ure
of symptoms that gave no small degree of obscurity  to the  real
nature of the complaint.  The bowels were at this time obstinateh
costive, the  pulse at a medium of a hundred and thirty strokes in a
minute, but  varying from  ten strokes above to  ten below;  there
was a short,  dry,  distressing  cough,  and  a  slight  difficulty of
breathing; yet no  observable pain about the right shoulder: the
skin was nearly of its  natural hue ;  the motions, when procured,
rather less yellow, and the urine rather more  so than in common
health ; the nights were  without rest,  and very fatiguing.   The
result of the symptoms had hitherto rather led to an idea of mischief
in the chest; but finding on examination that there was a consider-
able degree  of tension  and tenderness in the hypogastrium,  rather
verging towards the right,  and connecting these signs  with the
preceding, I had no hesitation  in pronouncing the disease  to be
hepatitis, and the opinion was unanimously* adopted.
  As the pulse, from the length of time the disease had  now  con-
tinued, would  not allow of general bleeding, twelve leeches were
instantly applied to the region of the liver; an active cathartic was
prescribed, and the patient put upon a course of calomel and anti-
monial powder,  of the former of which he took  three or  four
grains a-day ; with an opiate at night.  And, after the application of
the leeches, a large flannel wrung out  in  hot  water, was applied
over the whole of  the abdomen, and confined with a calico swathe,
in the manner  already recommended in peritonitis ; the  warmth and
moisture being rendered permanent by a renewal of the  hot-water
as soon as the  flannel became dry, though it rarely  required to be
changed oftener than two  or three times in the twenty-four  hours.
The application was peculiarly grateful to the patient.
  By this process a very favourable impression appeared  to be
made on the disease from the first; the pulse  sunk to less  than a
huudred  and twenty, and  sometimes  to  less than a hundred ; the
cough was less troublesome, the  nights  more  refreshing, and the
patient was able to retain more food.   One of the  most obstinate
symptoms was the  costiveness, which no ordinary  aperient, even
though aided by injections and the use of the calomel, was capable
of  alleviating; and  which  was  only occasionally  relieved by a
combination of extract  of jalap with  that of aloes or gamboge, or
both.
   In  about  a  fortnight  however, all  the symptoms became more
violent;  the pulse rose to  a hundred and forty, the cough  was more
troubl^ome ;  the tension over the abdomen was more general, and
there was an evident fluctuation over the whole abdomen, indicative 
GE. VII.-SP. XIII.]
SANGUINEOUS FUNCTION.
265
  of ascites.  The fomentation was omitted but  the calomel was con-
  tinued, and elaterium, gradually increased to three grains at a dose,
  in conjunction with the same quantity of extract of jalap, was given
  as a purge.   In no  proper proportion however did it operate as
  such ;  it sometimes produced a watery evacuation or two, but never
  to any extent, and occasionally excited  vomiting.   It was omitted,
  and the digitalis, in unison with infusion  of roses doubly acidulated,
  was given in  free doses together with  the calomel.
    At this time a violent shivering-fit took place, which made the
  teeth chatter; the pulse seemed rather to remit in rapidity, but the
  night   was passed in hectic  perspirations.   Suppuration  had  no
  doubt   commenced.   The digitalis and calomel were omitted, a
  strong  infusion of columbo acidulated with equal parts of nitric and
  muriatic  acid prescribed in its stead;  the  right  hypochondrium
  was covered over with a large  plaster  of the emplastrum ammoniaci
  cum hydrargyro; animal food was enjoined,  and a small quantity of
  wine  allowed.    All the symptoms  once  more diminished ; the
  tension and  perspiration subsided, the  fluctuation  was  lost, the
  cough  ceased, and the  nights  were refreshing.  The patient con-
  tinued to amend about a fortnight, when  the morbid symptoms again
  returned,  though in a  slighter degree,  and seemed to  show that
  some other part of the liver wasgaow affe<?ted. The former treat-
  ment  was resumed;  leeches, succeeded by an ammoniac-mercurial
  plaster, were applie 1 to the part affected ; calomel was  given in
  the proportion  of two  grains a day, but the tonic  regimen, in the
  debilitated state of the patient,  was not relinquished.  In a few days
  this plan also was found to produce a beneficial effect: every symp-
  tom again subsided ; and the little patient, in about three months
  from the  commencement of the disease,  was restored  to perfect
  health.
    It is  clear that in this protracted and complicated  case the liver
  was successively attacked with inflammation in different parts ; and
  that, had the whole  advanced to suppuration,  and  opened external-
  ly, there would  have been distinct sacs or abscesses in succession to
• each other.  And  it appears also, from the history of the symptoms,
  that the first and last  inflammations were carried off by resolution ;
  and the second by  suppuration, the pus  being absorbed and the cavity
  healing withoiit exposure.
    In chronic hepatitis all the specific symptoms, as already observ-
  ed, show themselves obscurely.   Tree pulse is something quicker
  than usual, and  there is an obtuse pain in the region of the liver;
  but such  as would not perhaps be noticed if it were not  inquired
  into and the organ pressed upon ; and there is also an indistinct un-
  easiness generally, though  not always,  about the  right  shoulder.
  But in conjunction with  the  proper  hepatic symptoms,  the most
  obvious are those  of dyspepsy and atrophy ;  the appetite  fails, the
  stomach is capricious, the animal  spirits flag, and the flesh wastes
  away.   The bowels are generally costive, and the stools often clay-
  coloured,  though  not always;  and there is usually a sallowness on
    voft.  ii.                  34 
266
HjEMATICA.
[CL. I1I.-OR. lh
the skin.   The disease slowly advances to suppuration,  or termi-
nates in a scirrhous induration; but in many instances, and especial-
ly after a habit of hard eating or drinking, is the index of a  broken-
up constitution.                                         ,
   Excess in eating and drinking, or indeed in any other voluptuous-
ness, is the common cause of this variety of hepatitis in temperate
regions ; though it sometimes follows upon obstinate quartans.  It
is, however,  a more  frequent affection in hot  climates, where, as
already observed,  it is far more apt to occur than  the preceding
variety.   And it is on this  account we see so many persons return-
ing annually to our own country from the  East or West  Indies, with
enlarged livers, irregular fever, indigestion, costiveness,  fulness in
the right hypochondrium,  white stools,  yellow  complexion, dry
cough, disturbed sleep,  and dejected spirits ;  occasionally  some of
these symptoms being wanting, and occasionally others.   In  all such
cases the  organ  is torpid,  debilitated,  and irritable, and the cure
must depend upon our ability to give it fresh tone and vigour.  The
general congestion is most  effectually removed by smaller doses of
calomel than  advised  in the acute variety, so as to  produce  an
alterant  effect, and gently  excite the sluggish secernments into a
state of renewed activity.   And, in conjunction with these, we are
to employ warm aromatic bitters;  and, where they agree with the
stomach, the  mineral acids.   Dandelion, as recommended by Boer-
haave, and Bergius, has often been found  serviceable.  Dr. Pem-
berton has of late paid much attention to its virtues, and has seen it
of decided advantage in incipient scirrhosities of the liver and other
abdominal  organs;  and  strongly recommends  it in  doses of half a
drachm of the extract twice a-day.*  We cannot,  however, always
depend upon this preparation, and hence, as a  general rule, it will
be more adviseable to  employ the decoction.
   In slighter  cases,  which have  nevertheless  compelled a return
from India after a residence Nof eight or nine years, I have found  all
the symptoms vanish before a steady use of Plummer1s or the blue-
pill, taken every night for  a  month;  and the  Cheltenham air and
waters, for the same period of time, afterwards.                  f
   Where a chronic  inflammation of  the  liver has terminated in a
scirrhus  of the whole organ or of a great  part of it, the blood is ob-
structed  in its circulation, congestion  takes place in other organs,
and we often meet with very extensive hemorrhages from the lungs,
nostrils,  stomach,  or anus,  ^ese discharges  are rarely,  perhaps
never, of service in  chronic cases, and only contribute to  weaken
the  system.   But in  acute  cases, constituting  the first variety,  by
diminishing the phlogotic action, they are often of very essential
use in inflammation of the spleen  as well  as of the liver;  and may
perhaps  be regarded as critical.  BoerhaaveT has  quoted, upon this

   * Treatise on the Diseases of the Abdominal Viscera.
   t Van Swieten Comment. } 923-4.  Hippocr. in Prognostic.  Tom. vm. p. 613.
(>aleu. De Ciisibus. lib. in. cap. iv. 
GE. VII.-SP. XIII.]    SANGUINEOUS FUNCTION.              267

subject, the remarks of Hippocrates and Galen, in  confirmation of
this fact;  but they seem  to have laid down an unnecessary distinc-
tion in contending that the hemorrhage from the nose, in order to
be critical, must take place xxr ivivapixr, or in a direct line ; in other
words, from the right nostril in inflammation of the liver,  and the
left in inflammation of the spleen;  for we have numerous examples
of benefit in both  affections from which side soever the  blood has
issued.
                        SPECIES XIV.

                EMPRESMA SPLENITIS.

                Knflammatton of the Spleen.

 BEAT, FULNESS,  AND TENDERNESS IN THE  SPLENIC REGION ;  WITH  PAIN
                          UPON PRESSURE.

 Of the use of the spleen,  as observed in the Physiological Proem
 to the first class, we know little or nothing.   It secretes no peculiar
 fluid except what serves  to produce a  change in its own  blood,
 which is of  a dark livid colour, and coagulates with difficulty.   It is
 commonly supposed to be an organ auxiliary to the liver; and  it is
 unquestionably subject to all its ailments; voluptuous living, how-
 ever,  and even the heat of a torrid sun, affect it less;  but obstinate
 tertians  and  quartans  more, and render it sooner congestive  and
 scirrhous.
   Inflammation of the spleen, together witBWhe symptoms given in
 the definition, is  accompanied with the usual  pyrectic signs;  and
 often with a pain extending over the whole of the  abdomen, but
 particularly in the left side, and shooting  from the  diaphragm to
 the left shoulder.  There is also not unfrequently a dry, short cough,
 and sense of constrictfon in the praecordia, sickness or  nausea, and a
 discharge from the rectum of black or livid blood, from a rupture of
 some of the splenic vessels.
   The common causes of inflammation of the spleen, are  the same
 as those of the liver;  and the treatment needs not essentially vary,
 as the progress and terminations of the  disease are  not  different.
 In India, where it is more common than  in temperate climates, the
 native practitioners use punctures and scarifications.
   The splenalgia, or pain in the spleen, of many writers, is for the
 most part a slight attack of this disease  with some small degree of
 fever: and parabysma splenica, is a frequent  result of both.   In this
 last state the  organ has  been sometimes extirpated, either partially
 or wholly, without injury to the general health.*

«Z ^' N?ooCur' DeC' r Ann-,V'  Vl0bs- 1C1* Ann- VXI-  0b3- 15°- Valisiieri.
^>pp. III. p. 128.                                                  ' 
286                     hjcmatica;             [cl. nr.-oR. 11.


                        SPECIES XV.

              EMPRESMA  NEPHRITIS.

              Inflammation of the  liftmen

PAIN IN THE  RENAL  REGION ; FREQUENT MICTURITION ; VOMITING ; NUMB-
  NESS OF THE  THIGH  ON THE  AFFECTED SIDE ;  RETRACTION OF  THE
  TESTICLE.

The general causes of this species are whatever obstructs the flow
of the fluids in the vessels of the kidneys ;  as a wound, contusion,
tumour, strain of the muscles of the back that press on the kidneys,
excess of horse-exercise, various acrids conveyed to the kidneys by
the course of the circulation.   It is, however, most frequently met
with as a  secondary disease, resulting from calculous matter block-
ing up the tubuli uriniferi, or  from calculi formed in  the pelvis of
the kidneys, and obstructing that cavity or the  canal of the ureters,
concerning  which we shall have to treat  under the genus lithia,
embracing calculous concretions in the urinary passages.
  The symptoms enumerated in the specific definition are sufficient
to indicate the presence of nephritis, though the numbness and re-
traction of the testicle are common to calculi in the ureters or body
of the kidney, even when there is  little inflammation present.  In
the case  before us, however, the skin is usually hot  and dry, the
body qostive, and motion, and even an erect position, is accompani-
ed with considerable uneasiness.  By the last  sign we may distin-
guish the disease from an inflammation of the psoas,  or almost any
other adjacent musclefvvhile the immediate seat of pain separates
it from colic, even  when it is  attended, as it is occasionally, with
ventral gripings.
  Where the  disease is violent, the urine  is  discharged  in small
quantity, and of a pale hue.  And hence, if tlje urine become high-
er coloured, be secreted in a larger proportion,  and be at length
thick and  mixed with mucus, a gradual  relief may be expected to
follow, and  the cure will be effected by a copious flow.  The dis-
ease sometimes passes off also by a metastasis.   But if the symptoms
be protracted beyond the seventh day, and there be stupor or heavi-
ness in the organ,  instead of acute pain, with frequent returns of
chilliness and shivering, we have reason to expect that an abscess
will ensue : in which event the pus may  be discharged into the
pelvis of the kidney, the abdomen, or, in case  of  adhesions, exter-
nally through the integuments  and the skin.  The  first is the most
favourable issue, next to that of resolution ; the  last is often suc-
ceeded by a cure, but an evacuation of  pus into the cavity of the
abdomen rarely.  In some instances the suppuration has been so
considerable as to destroy the substance  of the affected kidney en- 
GE. VII.-SP. XV.]     SANGUINEOUS FUNCTION.              269

tirely,  and leave  nothing but the external membrane.  Yet there
are cases in which a patient has recovered even in this state, and
the office of secretion  has been  performed  by the sound kidney
alone.
  Gangrene occasionally ensues,  and is indicated by a  sudden re-
mission or cessation of pain; after great violence of vascular action;
accompanied with cold sweats, a sinking pulse, discharge  of black
urine,  and the other symptoms of approaching dissolution.
  In attempting  a cure  of nephritis, we should  commence  with
copious bleeding; and in this case we may most conveniently employ
cupping-glasses, applied to  the region of the  kidnies.  Saline  pur-
gatives should  follow; and then oleaginous or mucilaginous emul-
sions, with small doses of nitrate of potash, or tincture of  digitalis.
The last has often proved  highly  serviceable in taking off the ar-
terial action that  maintains  the  inflammation, and at the  same time
in augmenting the urinary secretion.  The  loins should, at  the
same time, be covered with a large folded flannel wrung out in hot
water, and confined as  already described in the case of peritonitis;
and copious emollient injections should be  frequently thrown up the
rectum, and suffered to remain there as  long  as the patient may be
able to retain them.  The rest of the treatment and regimen should
be that of inflammation in general.
                       SPECIES XVI.

                EMPRESMA CYSTITIS.

              Inflammation  of the Iftatf&er

PAIN AND SWELLING  IN THE HYPOGASTRIC REGION ; PAINFUL OR OBSTRUCT-
                ED DISCHARGE OF  URINE ; TENESMUS.

The bladder is often irritated and inflamed by viscid substances that
pass into the  circulation, and particularly  by cantharides,  ardent
spirits, and terebinthine essences or balsams.  Idiopathic  inflamma-
tion is not a frequent disease ; yet it occasionally occurs as the blad-
der is subject to  the common causes of inflammatory affection : and
it takes place both in its  exterior  coat, and internal mucous mem-
brane.
   If the lower part of the bladder be chiefly affected, the pain will
extend to, and take the course of the perinaeum.   If the seat be  in
the neck of the  organ, there will be  a retention of  urine  with a
constant  urgency to  evacuate;  if in the  fundus, the urine  will
flow stillatitiously, and without  ceasing; the  bladder will give a
feeling of being  constantly  full;  and  the patient  will be perpetu-
ally and fruitlessly striving  to empty it.  In this  affection there  is 
270
H^MATICA.
[CL. IH.-OR. II.
usually great restlessness and anxiety, with cold extremities, vomit-
ing, delirium, and other marks of great general irritation : the dis-
ease runs its course with rapidity, and subsides, or destroys the pa-
tient, in  a few days.
  It terminates, like all other inflammations, most favourably by re-
solution.   But if this do not take place, it passes on to suppuration
or gangrene ; the diagnostics of both which  are those already no-
ticed in the preceding species.  If suppuration take place, the pus
may be discharged by the urethra, which is its happiest outlet; or it
may follow the course of the ulceration, and be  emptied into the
cavity  of the  abdomen;  or, if adhesions have been formed with the
subjacent cellular membrane, it may work its way  in a sinuous di-
rection and find an  opening in some part of the perinaeum.  Of the
last two terminations the first is almost always fatal;  and the second
is extremely  troublesome and  tedious,  though  a cure is usually ef-
fected  at last.
  Repeated bleedings, aperients, and relaxants, with copious emol-
lient injections, suffered  to remain in  the rectum as long as possible,
form the  chief part of the plan of cure.  Blood  should  be drawn
both generally and  locally, and a large bladder about half full of
warm water be kept  constantly over the  pubes.  The  warm  bath
has also been frequently of essential  service.   When the urine is
actually suppressed, it must be  cautiously  evacuated by a catheter.
                      SPECIES XVII.

             EMPRESMA HYSTERITIS.

               Inflammation ot the Womo.

iPAIN, SWELLING AND  TENDERNESS  IN THE HYPOGASTRIC  REGION ;  HEAT,
  PAIN  AND TENDERNESS IN THE OS  UTERI :  VOMITING :  PULSE RAPID.

This species offers us  two varieties,  according  to the condition of
the organ at the time  of attack:—

x Simplex.                    The  organ unimpregoated.   Pain
  Simple Inflammation of the    permanent, circumscribed, throb-
    Womb,                     bing: fever a cauma.
£ Puerperarum.               The  organ having  lately  suffered
  Puerperal Inflammation of       child-birth.   Pain less acute, less
    the Womb.                  circumscribed:   flow of  urine
                                difficult:  fever a synochus or ty-
                                phus.

  The  first of these  is produced  by cold or any of the other ordi- 
CE. VII.-SP. XVII.]    SANGUINEOUS FUNCTION.             271

nary causes of inflammation, and terminates in resolution, suppura*
tion, scirrhus, or gangrene.   The  most ordinary termination  is
that  of  resolution :  the  next  that of scirrhus, sometimes running
into  cancer:  both  which are far more common to  women who
have never been impregnated, than  to those  who have  had fami-
lies.   The concomitant symptoms vary  according to the  part  of
the organ in which  the  inflammation is seated.  If this  be chiefly
in the  fundus, the greatest distress  of pain,  heat, and  throbbing,
will be  above the  pubes; if the  posterior part be  chiefly affect-
ed, the loins  and  rectum will principally sympathize,  and  there
will  be  a troublesome tenesmus: if the inflammation attack the an-
terior part, the bladder  will participate in  the ailment;  the urine
will  flow with difficulty, but there will be a perpetual desire to pass
water:  while if the sides of the uterus or its ovaria be  chiefly in-
flamed, the pain will dart down the interior of the thighs.
   All the ordinary means already noticed for subduing inflammation,
both general and local, should here be put into effect without loss of
time, as venesection, aperients, emollient injections  both into  the
rectum  and uterus itself, and fomentations or epithems to the hypo-
gastrium.  The disease  is sometimes  cured  by  a  metastasis, and
sometimes by a sudden  flow of the  menses,  with hemorrhage  or
genuine blood.
   The  second variety, in which the symptoms are alike, but less
acute, is usually, though not always a result of suppressed lochia, or
violence sustained during labour, particularly from  the  use of in-
struments.  Bleeding is  here to be avoided ; and  the inflammation
to be attacked with gentle laxatives, diaphoretics, and, where there
is much irritability, camphor and  opiates; fomentations  and injec-
tions being employed at the same time.
   It  is  a singular but well ascertained fact, that  the  spleen, from
some unknown cause, is  peculiarly apt to sympathize with the ac-
tion of the womb, and at times, to run into an equal degree of inflam-
mation,  suppuration, or even gangrene ;  and especially in  females
of a high nervous temperament.  And so  common is this fellowship
of action, that most of the cases of diseased spleen related by Mor-
gagni, are accompanied  with an account of some mischief existing
in the womb or its appendages.  It is, however, to M. Gastellier of
the Hospice de la Maternite, at Paris, that we are chiefly indebted
for a knowledge of this  peculiar sympathy, and  especially  in the
case of uterine inflammation after child-birth.  " La rate," says fe,
" en a ete souvent frappee, mais une fois entr' autres elle a ete entiere-
ment detruit, entierement fondue : iln'en restoit aucune trace, si non
un foyer delfluide sanieux, dans la region, et en place de cet organe."'
   This passage from M.  Gastellier is quoted  by Dr. Ley, in a case
of a similar kind which lately occurred to himself in the Westminster
Lying-in-Hospital, and is given in the Medical  Transactions  of the
College.*  In this case, the preceding  labour seems  to  have been
* Vol. v. Art. xx. 
272
HiEMATICA.
[CL. III.-OR. II.
perfectly natural and without any difficulty whatever.   On the third
day afterwards the disease seems to have commenced,  indicated  by
intense pain over the whole  of the abdominal region, with  a slight
sense of fulness, but without any considerable degree of  tension.
The patient sunk suddenly seven or eight days  afterwards, and at a
time when she was supposed to be in a state of improvement.  On
examining the body, the peritoneum and intestines  exhibited little
morbid affection  of any kind ; and the disease was found  limited to
the uterus and spleen:  the peritoneal covering of both was slightly
inflamed, but the internal structure of both had undergone  a very
extensive  destruction.   The whole  surface of the  uterus, when
stripped of its tunic, was found to assume a gangrenous appearance,
was extremely irregular, of a. dark,  livid  hue, and  gave  forth  a
highly offensive vapour.  The texture of the spleen was so changed
as to resemble an extremely  soft piece of sponge, and its cells were
filled with an intimate mixture of pus and grumous blood.
                      SPECIES  XVIII.

               EMPRESMA  ORCHITIS.

              Inflammation of the 3Testfcles/

PAIN AND SWELLING OF THE TESTICLES ; NAUSEA OR VOMITING J DEPRES-
          SION OF SPIRITS ; PULSE QUICK, SOMEWHAT LOW.

Inflammation of the testicle has generally been expressed by the
absurd and unmeaning name of hernia  humoralis ; which, however,
in its earliest use, applied to only one stage  of the disease, namely
the  suppurative, and imported an abscess or  collection of pus in any
part of the scrotum ;  and in this sense the expression occurs in Heis-
ter  and Dionis : being precisely synonymous with the empyocele of
the Greeks.   I have revived the Greek term orchitis, not only as
being far more precise, but as accordant with the general termina-
tion of the specific names of the diseases appertaining to the present
genus.
^The inflammation  seems commonly to commence in the tunica
vaginalis,  and to  pass secondarily into the  substance of the testis.
Dr. Schwediauer contends that the testis never swells in the  first
instance, and  that the disease always begins in the epididymis.
The causes are irritation or external injuries.   The most common
irritation is venereal virus.  Bleeding,  laxatives, and  cold lotions,
with a suspensary bandage, form the curative process.  Yet we have
already observed that, when all local  applications have proved in-
effectual, the inflammation has  been removed by vomits, in conse-
quence of the close sympathy between  the  testis and the stomach. 
GE. V1I.-SP. XVIII.]  SANGUINEOUS  FUNCTION.              273

  This was a frequent practice of Mr. John Hunter,* and especial-
ly when the  inflammation was  the result of a syphilitic taint.   It
was successfully employed  for the  same purpose,  and is  hence
strongly  recommended  by  Rhazes,t  and is a common  mode  of
treatment on the continent, particularly in Germany :J after  which
opiates are often had recourse to, as well externally as internally.
It  may  be  worth remarking, that the affinity  or play of  action
which thus prevails  between the testis and the stomach, does not
appear to be the common bond of union that is exhibited between
the stomach,  as the general centre of sympathy, and most  other
parts  of the system ; but a fellowship of a peculiar kind, and which,
in fact, does not terminate in the stomach, but extends to the  upper
extremity of the  alimentary tube,, and exercises  a very high de-
gree  of  influence over the parotid glands,  as is well known in  e.
parotitis, and has been already  noticed in  discussing this disease.
In treating of e. hysteritis, I have  had occasion to glance  at the
existence of a like  sympathy between the uterus  and the spleen :
and the physiologist who has time for such pursuits, and judgment
enough to guide him to a correct discrimination, would be engaged
in no  unthrifty employment if he were to follow up and arrange,
in a  regular  classification, these specific  and  mysterious relation-
ships, which single organs hold with single  organs, and which are
subordinate to the general harmony of the entire machine,
                    GENUS  VIII.

                     OPHTHALMIA.

        ©jjhthalmg.  Inflammation of the 33ge.

PAIN  AND REDNESS  OF THE EYE  OR ITS  APPENDAGES :  INTOLERANCE 0*
          LIGHT J FLOW OF TEARS OR  OTHER DISCHARGE.

Ophthalmia, from the Greek term oq>6xXfios, oculus,  is obviously of
very  extensive import, and, from its radical  signification, may be
applied to any morbid affection of the eye, unless limited by com-
mon consent.   Now, although a sort of common consent has been
given, so as to restrain the term  to inflammatory action, such con-
sent has  not been  universally acceded to ; and hence  ophthalmia
has been used in very different senses  by  different writers.  Thus,
        * On Venereal Diseases.
        t Continent. Lib. xi.
        X Althof, Piactische Bemerkungen, &cr.
        Giitanner, Venerische Krankbeiten, Sir,
vol.  ii.    •              35 
274
HjEMATICA.
[cl. Hi.-OR. II.
Sauvages, Linneus, and Sagar, employ it as expressive of any ache
of the eye, without reference to pyrexy or inflammation.  Amongst
all these,  therefore,  it  occurs under their class dolores, and1 runs
parallel with cephalalgia or cephalaea, ache or  pain in the head.
By Vogel,  Cullen, and  Macbride, it is limited to inflammatory af-
fections of the eye; the  two former arranging it as a genus, and
the latter as a  species.   By Dr. Parr and Dr. Young it is  also ar-
ranged as a species, and limited to phlogotic action ;  the second
denominating it ophthalmitis, consonantly  with the common termi-
nation  of names importing inflammatory  diseases  of a particular
description of internal membranes, and organs.
  In the  present system ophthalmia assumes  a middle  rank: it is
limited to inflammatory  action accompanied with  organic pain, but
is  arranged as  a genus.   It might  possibly have been placed as a
species under  the preceding genus, empresma, in  which  case it
should have been written, as Dr. Young has written it, ophthalmitis:
but it has various characters peculiar  to itself, as  well in regard to
its symptoms, as to the particular parts of the organ affected, which
seem to  entitle it to the  rank of a distinct genus.  And thus ex-
plained,  its real meaning will be found in the generic definition;
the symptoms of inflammation common to the  order, and entering
into the ordinal definition, being always understood as a part of the
generic character.
  There is, perhaps, no disease in Dr. Cullen's First Lines that is
treated of so  slightly and unsatisfactorily as opthalmy.  He gives
only one  idiopathic species, into which he resolves all inflammato-
ry affections  of the  eyes  that are  not symptomatic of other com-
plaints ;  and he considers this merely as modified into two varie-
ties, from the  inflammation being seated in the membranes of the
organ, or on the edge of the lid.   When we compare this abbreviat-
ed view  of the inflammatory diseases of the eye with Dr. Plenck's
methodical arrangement of its ailments altogether, and behold the
latter enumerating not less than  one hundred and nineteen genera,
comprising very nearly six hundred species, although  a regard to
our own  ease may dispose us rather to take part  with the abbrevi-
ating spirit of Dr.  Cullen than the discursive genius of Dr. Plenck,
still it is  impossible for us not to perceive that the former has been
too summary in his arrangement; and, if we follow up his arrange-
ment into his  therapia,  too summary in his  therapia  also.  It is
true, indeed,  that since Dr. Cullen's time, the   maladies of this or-
gan seem to have  increased, and this too, in one at least,  perhaps
more than one, of its most virulent and fatal affections,  as  the con-
tagious purulent ophthalmy ; but then this addition has taken place,
also, since the  arrangement of Dr. Plenck, who  would otherwise,
no doubt, have found the means of extending his list by the inven-
tion of new genera and species, to nearly a hundred more maladies
of the  eyes ;  so as to have treated us with a catalogue of nearly
seven hundred, instead of six hundred, distinct diseases of this sinele
organ.                                                       5 
GE. VIII.]
SANGUINEOUS  FUNCTION.
275
  After no  small degree of consideration, it appears to me that
ophthalmia, or inflammation of the eyes,  may embrace all the dis-
eases that belong to it, as a genus, under the five species of inflam-
mation of its coats generally ; inflammation of the muscular fibres of
the iris ;  inflammation  of the internal surface of the eye-lids asso-
ciating with that of the globe ; inflammation of the  tarsus or edge
of the eye-lids; and the chronic  inflammation which is often found
as a sequel to most of these.
1.  ophthalmia taraxis.
2.----------IRIDIS.
3.---
4.  ---
S.  ---
— PURULENTA.
— GLUTINOSA.

— CHRONICA.
LACHRYMOSE OPHTHALMY.

INFLAMMATION  OF THE IRIS.

PURULENT OPHTHALMY.

GLUTINOUS  OPHTHALMY.

LIPPITUDE BLEAR-EYE.
           SPECIES I.

OPHTHALMIA  TARAXIS.

    aachrgmose <£jmthalmg.
INFLAMMATION SEATED, OR COMMENCING, IN THE TUNICS OF  THE EYE-
              BALL :  INCREASED  SECRETION OF TEARS.

This is the  common  inflammation of the  eyes  produced by cold,
dust, or any  other external  irritation, as excessive light,  vivid co-
lours, blows or wounds: and has been often  called, and with great
propriety, lachrymose ophthalmy,  as the morbid secretion  chiefly
excited is  that of tears.  By Paul of iEgina it was named taraxis,
from t%»»7vm  " to disturb,  confuse,  tumultuate," in allusion either
to the violent action  that takes place, or  the confusion of  the ob-
jects presented.  And as the Greek name has been very generally
continued by medical  writers,  and  especially  those of the Conti-
nent, to our  own day, I have employed it in the present system, to
distinguish the species before us.   It occurs  under two varieties as
follow:
x Mitis.
  Mild Lachrymose
     Ophthalmy.
S Acuta.
  Acute Lachrymose
     Ophthalmy.
The inflammation limited to the sur-
  face : the pain passable: the head
  not affected.
The  inflammation  extending to the
  lower  part of the eye-ball: and
  sometimes commencing  there: the
  pain burning:  the  tears  perpetual
  and  acrid:  with intolerable  head-
  ache. 
276                     H4MATICA.            [<*-  "I.-OR. H.

  The first variety is a very frequent disease in  most■ countries,
but particularly in those exposed to sudden changes in  the tempe-
rature of the atmosphere.  Clouds of dust, in dry  *"onJ.^ ""?;
ther common cause ; as is also an exposure to smoke, or  otheracrw
fumes or exhalations.   A strong incessant glare of light, or ot vivid
colours has also not unfrequently proved  a source of affection   but
perhaps less frequently so than an  undue use of wine  and ardent

SP The disease  commences with  the appearance of a net-work of
red blood-vessels  in the sclerotic  tunic, and particularly at the an-
gles of the  eye ; the eye-lids are often swollen and tender the toe
membrane  that lines their interior is turgid with blood, and there
is a feeling  as if  gritty particles had insinuated themselves under
the lid,  accompanied  with great heat and  a pricking pain.  If the
inflammation commence in  one eye it will generally extend  to, and
sometimes alternate with the other;  and during sleep  a glutinous
fluid is secreted  which collects towards the angles,  and sometimes
so closely cements the eye-lids,  that it is with difficulty they are
opened in the  morning.      >
  In ordinary  cases, this milder modification of ophthalmy runs its
course in  four or five days, and ceases spontaneously, or is  easi-
ly removed by local  applications,  and particularly astringent lo-
tions, as cold water,  or solutions  of alum,  zinc, or lead ;* though,
in irritable  habits of  a particular kind,  relaxants and  anodyne fo-
mentations prove most successful.   And  even when the first are
employed,  it is always best to wash off the adhesive fluid, that glues
the eye-lids together during the night, with a little warm water in
the morning, before a free  use of them.
  In the second variety, constituting the chemosis of  Plenck, and
produced from the same causes as the preceding, the symptoms
from the first assume great violence; the inflammation passes rapid-
ly from one part  of the ball to another;  a keen darting pain pene-
trates frequently  to the bottom of the socket,  accompanied with a
burning heat, and intolerable head-ache ;  the temples often throb,
and the pulse is quick.
  The most active measures are here necessary from  the earliest
commencement;  for,  from the violence of the inflammation, ulce-
ration may take  place internally or externally,  and the pupil be
irretrievably lost.  Copious bleedings by leeches  or cupping-glas-
ses, are usually recommended from  the temples; but large  and re-
peated general bleedings carried on to syncope will be found far
more successful ;  and if the blood be taken from the temporal arte-
ry, the success will be still  more certain.  Brisk purgatives should
at the same time  be employed, and blisters applied to the temples,
or behind the  ears.   The room should be kept moderately  dark,
but cool and airy; and astringent lotions, chilled by ice  or frigorific
mixtures, be constantly  applied to the forehead, temples, and eye-
lids, by folds of linen successively wetted for the purpose.
* Janin, Beobachtungen iiber das auge, &c.  Berl. 1776. 
GE. VIH.-SP. I.]      SANGUINEOUS  FUNCTION.              277

  I have  known, however, that the vomiting plan, which  I  shall
have to notice under  the  third  species, employed  here also  with
very great advantage, and in  some cases where  every  other  plan
has failed; and I find the same  practice had recourse to with like
success in a very strongly marked  case, published by  Dr. Robert
Dobson of Kirkham ;  who  tells us  that at  that time, 1773, there
was a rumour of the utility of emetics in some inveterate cases of
this kind, notwithstanding the general prejudice against  them,  from
their being supposed to add to  the  congestion of  the head.  The
patient,  whose  history he describes, was  a young woman,  aged
twenty-two, of a delicate habit.  The  attack was sudden, and  pro-
duced a total inability of sight in the  right eye.   The tunica  albu-
ginea, and indeed the whole globe of the eye  were preternaturally
enlarged, and the former  in a  considerable measure covered  with
deeply-inflamed  red vessels; the  cornea being greatly distended,
and the crystalline lens  apparently protruded, by an accumulation of
fluid, through the pupil so as to be  in contact with the inner sur-
face of the cornea itself, possessing an irregular and unequal form.
The eye-lids were very much swollen and glued together; the ad-
mission of light and air  was insupportable ;  and followed by a  copi-
-ous discharge of acrid tears;  and the whole was accompanied  with
excruciating and  incessant pain,  entirely  preventing  sleep, and
sometimes so  intolerable as to  induce fainting.  The left eye was
similarly  affected,  but  in a  less degree.   Copious  and  repeated
bleeding from the temples, blisters, purgatives,  shaving the  head
an;! cold applications to it, and all other means that could be thought
of, had been tried, but to no purpose.   As a  doubtful and desperate
remedy, a tartar  emetic  mixture was prescribed of which the patient
was to take a large spoonful every hour till it vomited  or purged
her.   The second dose both vomited and purged ; after  this at bed-
time, she took a grain and a half of Thebaic  extract with two grains
of ipecacuan.  She passed a quiet and composed night, and  enjoyed
more sleep, and  far more comfortably than she had done during all
her illness.   The  tartar emetic mixture  was continued  the  next
day in smaller quantities, and in a few days more she recovered her
former health and strength.*
  Where  the inflammation is a mere symptom or concomitant of some
other disease, it  can only be removed by a cure of the original ma-
lady.  And this is not unfrequently the case ; for it is often depen-
dent on a strumous, or syphilitic habit or a suppressed blenorrhcea :
on a disordered state of  the stomach, liver or some other  digestive
organ, and especially in  hard drinkers; on an abuse  of mercury as a
medicine  ; and on various affections of the teeth.
  If the inflammation  be produced by an influx of sand  or gravel,
or spiculae of flint or iron driven into the external tunic,  every  such
foreign substance must  be  carefully removed with as much speed
as possible: but  it will be generally  found that the pointed and
Edin. Med. Com. in. p. 411. 
278                      H/EMATICA.           [CL. HI.-OR. II.

pricking pain caused by the incursive substance will remain for
some time  after its  removal,  and induce in the patient's mind  a
strong  belief that it is still fixt  in the membrane.  We have vari-
ous examples of an extraction of spicule of iron forcibly driven int«
the eye, by the application of a magnet.*
                         SPECIES  II.

                OPHTHALMIA  IRIDIS.

                 Inflammation ot the Ins.

inflammation commencing in the  iris ;  COLOUR changed to  GREEN
  OR  REDDISH ; FIBRES  LESS  MOVEABLE ; AND  SHOOTING  DENTIFORM
  PROCESSES INTO  THE  PUPIL ;  PUPIL  IRREGULARLY CONTRACTED  AND
  GREYISH.

Dr. Schmidt of Vienna, to whom we are chiefly indebted for an ac-
curate description of this  species, has denominated  it  Iritis ;t and
under this name it has of late years been described by many practi-
cal surgeons in our own  country.  The  termination, however,  is
unclassical, and if the derivative be retained, it should unquestiona-
bly be iriditis instead of iritis;  but ophthalmia iridis is better,  as
the disease is very clearly a species of  a  connexive  genus of dis-
eases rather than a distinct genus itself.
  The exact change of colour which  the inflamed iris assumes, first
in its less, and then in its greater circle, depends  upon the peculiar
colour it possessed when in health.  If  this were greyish or blue,
the morbid hue will be green ;  if brown or black, it will be reddish.
The greyish or cloudy appearance of the pupil is produced by the
secretion of coagulable lymph  which spreads over it in a fine flake
like  a cobweb.  If the  inflammation do  not  yield to the curative
treatment,  a yellowish red tubercle forms  some part of the surface of
the iris, commonly where the greater and  less circles of the mem-
brane meet; it enlarges, projects  still  forwarder, and  is distinctly
seen to be  an abscess  which  at length bursts and  discharges its con-
tents into the anterior chamber.  The  inflammation  now diminish-
es, the pus and blood, if any be thrown forth, are absorbed; and the
disease subsides, but with a total loss  of vision ; for the  iris remains
permanently expanded with an  utter  inability of motion, and the
  * Morgagni, De Sed. et Caus. Morb. Ep. xm. 22.
  Weber, VVurkung des kiinstlichen Magnets in einem Augenfeler, p. 18.  Hanov.
1767, 8vo. Phil. Trans, p. 164.
  t Ueber Naclmaar, und Iritis Nachstaav operationem. Wien. 1801. 
GE. VIII.—SP. II.]      SANGUINEOUS FUNCTION.             279

pupil is closed or rather filled' up by the  greyish or ash-coloured
web or membrane already noticed.
  The most frequent cause of this distressing affection is the opera-
tion for the  cataract; in which an irritation is often excited either
by endeavouring to press out the lens through too small a wound
in the cornea ;  by suffering some pieces of the lens to remain in the
posterior chamber; or from too frequent an exposure of the inter-
nal  surface  to  the air by unnecessarily  raising  the flaps of  the
cornea.
  Like several other species of ophthalmia, this  also  occasionally
shows itself during the  existence of a syphilitic taint in the system.
And where a patient is labouring under an arthritic diathesis, and  is
accidentally affected by a common ophthalmy, this species is apt to
be engrafted upon it.
  The  medical treatment is  both  local  and general.   The  first
should consist in freely emptying the vessels by venesection, leech-
es,  and active purgatives: blisters  are then to be applied succes-
sively to the temples, behind the ears, and on the  nape of the neck.
Cold local applications  are quite useless; and the  only admissible
collyrium is a fomentation of the  eye with water made as hot as the
patient can  bear it, which will often mitigate the  violent pain;  the
eye being carefully wiped dry after using  the application.
  The general treatment of the disease consists in the introduction
of mercury into the system.   This  is particularly insisted upon by
Mr. Travers, who has written a valuable article  upon the subject.
Whether it be a primary affection, or connected with  other diseases,
even with syphilis, or induced by the action of mercurial prepara-
tions, he estimates this as almost a specific remedy.*
  Mr. Travers distinguishes also inflammation  in  the iris from  that
in the cornea, by regarding the latter as suppurative, and leading to
an abscess, and the former is adhesive alone.   And  he tells us  that
inflammation of the cornea so strictly maintains this  character,  that
if it spread to the iris, and in  this case become merely secondary, it
still preserves its adhesive power.
  This species is also sometimes a  concomitant of cutaneous erup-
tions, decidedly not syphilitic ;  and especially of .those  produced by
a very extensive use of mercury ; constituting what has been deno-
minated by some  writers erythema mercuriale, and hydrargyria,  as
we shall take occasion to notice under syphilis.
   In the syphilitic or arthritic affection however,  a particular atten-
tion must be paid  to  the primary disease, since   otherwise no local
remedies  can be of any avail.
* Surgical Essays, &c. i. passim. 
 280                     HiEMATICA.           [CL. 1I1.-OR. II.


                        SPECIES  III.

           OPHTHALMIA  PURULENTA.

                   $nrnlcnt ©jriithaimg.

THE  INTERNAL SURFACE OF THE PALPEBR* ASSOCIATING IN THE INFLAM-
   MATION  OF  THE  EYE-BALL :  COPIOUS  SECRETION  OF  A  PURULENT
   FLUID.

Of this species there are four varieties that are peculiarly worthy
of notice, though one or two  of them are  of more importance than
the rest:

x Epidemica.                 The disease epidemic; inflammation
   Egyptian ophthalmy.          rapid  and  destructive,  producing
                               irritating granulations on the inner
                               surface  of the  palpebral:  head-
                               ache intolerable; often  succeeded
                               by delirium :  at times remittent.
£ Metastatica.                Apparently produced by  a sudden
  Metastatic ophthalmy.         suppression of catarrhal, blennorr-
                               hoic, or  other  morbid discharge ;
                               the secretion  often greenish.
y Intermittens.                Marked  by  irregular  intermissions
  Intermittent ophthalmy.       nearly allied to the epidemic varie-
                               ty.  Probably produced  by a pe-
                               culiar miasm  generated in marsh-
                               lands.
i Infantum.                   Appearing suddenly and without any
  Purulent ophthalmy of in-     ostensible cause  in new-born in-
     fants,                      fants:  the palpebral florid, and pe-
                               culiarly tumid.

  The first, or Egyptian variety, is that concerning which so much
has of late years been written by French  and English surgeons and
physicians, and which proved so extremely destructive to the armies
of both nations in their respective expeditions to the  banks of the
Nile ; the real nature, however, and cure of which have  only been
very recently discovered in  our own country, to  the great benefit
of the numerous  blind pensioners of Chelsea and Greenwich hos-
pitals.
  This disease was at first ascribed  to the minute  and glassy spiculae
of the sands of the Egyptian plains.  But it has  since been sufficient-
ly traced, either to a peculiar miasm generated  in  marsh-lands, or to
sleeping on damp or swampy ground, with  insufficient covering, and
surrounded by a moist atmosphere.   And as these causes exist in 
GE. VIH.-SP. III.]   SANGUINEOUS FUNCTION.               281

other parts of the world than Egypt, the disease has been since  de-
tected in other parts as well.
  A peculiar miasm,  however, formed in hot and swampy  soils, is
perhaps the real cause ; for it  is otherwise almost impossible to  ac-
count for no existence or description of the disease in earlier times:
and  however difficult it may be to conceive  the  origin  of such a
miasm in one period of the world rather than  another,  this is a diffi-
culty that  extends  equally  to all  infections,  as  well  as to various
other maladies.  The cause, be it  the one or  the other, necessarily
renders it epidemic; and the pus, as in one or  two of the succeeding
varieties, secreted  apparently from the sebaceous, or rather  the
mucous follicles of the tunica conjunctiva (for  M. Bichat is probably
right in regarding the Conjunctiva as a mucous membrane) is  im-
pregnated  with a specific  contagion ;  and hence the disease is pro-
pagated  with great rapidity between those  who come in contact
with each  other, by sleeping together,  or using the  same towels.
I have known it caught by a surgeon's  assistant merely in conse-
quence  of syringing the  eyes  of a patient, a  part of the  discharge
having, from the force of the syringing, spurted into one of his own
eyes, which was for some days in a State of danger.
   The general  symptom* and progress of the disease  are  those al»
ready noticed in the  definition.  From the violence of the morbid
action,  the eye-lids soon become  excessively tense and edematous,
sometimes inseparably closed, with the edges drawn  inwards,  and
sometimes gaping with the edges broad, turgid, and everted.  The
secretion of pus  and tears is prodigious; and the pus  is discharged
thus  freely even when there is no ulceration.   But an ulceration
often takes place, and sometimes during the first night  of the attack.
It commences usually in the cornea,  which,  from the onset of  the
disease, looks more or less muddy, or is studded with white  spots.
The  ulcerative  progress  is sometimes checked before it spreads
over the whole disk of the pupil, and, in this  case, the sight is par-
tially preserved. But, very frequently, it makes a rapid  and irre-
sistible  advance over the  entire  cornea, lays open  the iris,  and
works its way to the membranes, and even to the cellular substance
below:  in  consequence of which  the aqueous,  and a part of  the
vitreous humour escape,  the  iris protrudes, and more or less ad-
heres to the ruptured cornea, and  the eye loses its figure as well as
its power of vision.  The pain, through the  whole progress, is in-
tolerable :  in the eye itself there  is a sense of scalding or burning,
and an agony in  the head that  drives the patient mad.
   In some cases the symptoms are less violent, and gradually  sub-
side without ulceration, in three or four days; and especially where
the disease has been actively opposed by the  process we shall have
to  notice presently.  But innumerable granulations have, by  this
time, often formed upon the conjunctiva of one or both eye-lids,  and
a destructive  irritation is hereby  still kept  up, which becomes a
secondary source of blindness.
  The  earliest  mode of treatment pursued'by the French,,  as we
  vox., ii.               3G 
282
KffiMATICA.
[CL. III.-OR. It'
learn  from the account of Dr. Antonio Savaresi,  consisted in httle
more  than the general treatment of the common  acute ophtna.my,
as local bleeding, drawn,  however, from  the  jugular vein or tem-
poral  artery,  blisters, saline purgatives, anodyne  lotions, and a low
diet.  The bleedings do not appear  to have been very  copious.
And yet this  writer tells us that by this  process alone  he was so
fortunate that  out of a thousand or thereabouts, who were confined
in the French military hospitals in Egypt  under his care, not more
than two lost their sight completely,  though some  others  suffered
the loss of one eye.
  In the hands of our own army practitioners the plan ot treatment
thus limited, completely failed of success j and the bleeding, which
was almost solely depended upon, was carried, from the first day of
the attack, and repeated for several days  afterwards to as  great an
extent, not only as fainting, but as life itself would allow.  The first
accounts we had of this practice  seemed to show that it was in the
highest degree successful :*  but later experience has not  justified
the representation, and the  extensive lists of blind pensioners at
this moment supported by the Chelsea and Greenwich hospitals, are
a sufficient proof that the success of the evacuating plan was consi-
derably exaggerated.
  The  late Mr. Saunders was, in consequence, induced to turn his
attention upon its full stretch to this most acute and maddening dis-
ease : and he was the first to discover that  the blindness which  is
so apt to follow, even after the first attack of virulent  inflammation
has subsided,  proceeds from the  friction upon the transparent cor-
nea, of innumerable irritating  granulations thrown forth from the
surface of the tunica conjunctiva that lines the interior of the pal-
pebral, and which become a new source of inflammation,  less violent
indeed, but as fatal in its effects; and the  disease has hence  been
very  correctly divided into two stages, that of primary  and that of
secondary or granulating inflammation.  Mr. Saunders endeavoured
to  cut the  disease short in its first stage by  exciting nausea, and
maintaining it for a considerable  period of time,  so as to lower the
living power, and  hereby take off the inflammatory action.   And
where the disease had proceeded to the  granulating  stage, he re-
moved the minute  caruncles from the tunica conjunctiva by cutting
them off with a pair of scissors, and afterwards applied a solution of
nitrate of silver to prevent their sprouting again.   Sir William Adams
appears very  essentially to have improved upon both plans.  Instead
of the nauseating process employed in the first stage, he boldly pre-
scribes active and powerful vomiting continued for  eight or ten
hours by giving two grains of tartar emetic at first, and continuing
one grain every  half  hour afterwards through  the whole of this
period;  by which violence  a change of  action,  or new but  more
manageable  excitement seems to be  produced in the  eye, and the

  * Account of the Ophthalmia which has appeared in England since the return of
 he British army. By J. Veitch, M.D. 
GE. VIII.-SP. HI.]  SANGUINEOUS  FUNCTION.               283

disease is stopped in the course of ten or twelve hours from its on-
set.  And where  the  second or granulating stage  has commenced,
he slices away by a knife the diseased surface of the conjunctiva,
instead of the granulating points alone ; by which the morbid action
is destroyed  not  only with less  pain, but  far more  radically and
effectually; and he afterwards employs a solution  of  alum, instead
of a solution of nitrate of silver, as the latter is hereby  rendered
unnecessary ;  not to mention that the agony it excites is almost in-
tolerable, and that a  new inflammation has followed, in some  in-
stances  almost as  dangerous as the original inflammation  itself.
Emetics, indeed,  have long  been  occasionally made use of as a
means of relieving inflammation in the eyes ; but not in the parti-
cular kind before us, nor,  perhaps at any  time of inflammation at
present  with  the precise object in view,  proposed by Sir William
Adams.  Stoll, for instance, employed them successfully in periodic
ophthalmies ;* and Dobson, as already observed, in ophthalmies of
a like chronic kind,  accompanied with nervous debility; the bark
being interposed between their repetition.?  The nearest approach,
however, to this practice which I have met with on medical records
is Dr. Dobson's case, already  noticed under acute taraxis.
   In the second or metastatic variety,  the inflammation of the eye
 is  produced by a transfer of action or secretion  from some other
 organ; as on  a sudden suppression of the discharge that takes place
 in  the nostrils during a catarrh,  or in  the qrethra  from venereal
 infection.
   The  mucous membrane  that lines the  ball of the eye, and is a
 duplicature of the tunica conjunctiva, has a near resemblance  to
 those  which  line the urethra and the nostrils,  and all are  easily
excited  to a very copious secretion of purulent matter.   This  in
effect is  the immediate cause  of the purulent ophthalmy in each of
its  varieties.   And it is not  therefore very extraordinary, as we
are perpetually  meeting with examples of a transfer of action in
 almost every other part of the body,  that the mucous membrane of
 the eyes should  occasionally  become the  seat of a metastasis  or
 transferred action from organs that so nearly partake of its nature :
 and it is still less wonderful that  such an effect should occur where
 the whole system is impregnated with syphilitic virus ;  a subject of
 inquiry, however, that belongs rather to the genus syphilis, than to
 the present place.
    The symptoms, under such a translation,  are those of the  Egyp-
 tian ophthalmy ;  the disease is often as violent and dangerous, and
 requires to be treated in the same manner.   1 have noticed this va-
 riety upon the concurrent testimony of St. Yves, Scarpa, Mr. Bell,
 and Dr. Edmonstone,  to which may be added the authority of Dr.
 Plenck, who  has two distinct varieties under the names of ophthal
* Nat. Med. Part H. p. 102.
t Med. Coinm. Edinb. Vol. m. p. 444. 
284
H.EMAT1CA.
[CL. III. OR. U-
mia catarrhal and o. gonorrhoea.  It  should  at  the  same  time be
observed that some very respectable  practitioners  still entertain
doubts upon the existence of a variety produced by any such means;
and are inclined to ascribe  the  disease, whenever it occurs, to  a
conveyance of the virus of the organ primarily affected to the eye,
by means of the finger, or of a handkerchief.  These doubts, how-
ever, appear to be founded  rather  on  hypothesis, and an indisposi-
tion to believe that  the conjunctive tunic ever secretes mucus, or
that there is any such thing as a consent of parts between  the re-
spective membranes before us,  than on any actual disproof.   The
variety seems to be supported by incontrovertible  experience:  and
M. Scarpa has pointed out a striking  difference between the trans-
fer of gonorrhoea to the eye by a consent of parts,  and the infection
of this organ  by an accidental communication of its virus ;  the dis-
ease being in the  latter case  always far milder than  in the formerj
I was lately consulted by Mr. G. of Great Russell Street, who  had
been  long labouring under  an ophthalmy that had assumed a chro-
nic and less violent character, and which appeared to be very much
of the present variety.   His former life had been irregular  : and he
had twice before had a clap suddenly cease upon a severe inflamma-
tion  of the  eye.  I had no reason to suppose that the present inflam-
mation was the result  of such  a transfer; but as he had been for
some weeks attended by a surgeon of considerable eminence, who
had already exhausted, although in vain, nearly the entire  treasury
of medical  resources, I could not  avoid observing that as there ex-
isted so close a sympathy between the mucous membrane of the eye
and that of the  urethra, probably the  most  speedy  and effectual
means of carrying off the present inflammation would be some acci-
dental irritation of the  urethra.   No steps were taken to effect
this; and I was, therefore, the  more astonished  at  finding about
three days afterwards that  such an irritation had accidentally occur-
red, accompanied with a considerable flow of  purulent  fluid from
the glans:  and 1 was  peculiarly pleased to find  that from this time
the ophthalmy began to diminish, and that a complete cure was ef-
fected in about a week.
   In the third variety, or that marked by regular intermissions, the
inflammatory symptoms are less violent than in either of  the pre-
ceding.  Its cause is uncertain:  and it has been suspected  by some
writers to originate in  a particular kind of marsh-miasm operating
upon a particular diathesis; and by others  to be connected with  a
syphilitic taint.  It is the ophthalmia periodica of Plenck.  The cure
is to  be attempted during the interval;  in which a free exhibition
of bark has been usually had recourse  to, though  where a vitiated
 habit is suspected, sarsaparilla,  or the inner bark of the elm in de-
 coction, or the solution of arsenic might be  tried  with  a  better
 chance of success.
   The fourth variety is  called by Mr. Ware  the  purulent oph- 
GE. VIII.-SP. III.]      SANGUINEOUS  FUNCTION.
285
thalmy of  new-born children,* and is at times as rapid and alarm-
ing as the Egyptian ophthalmy.  Its common cause is cold; though
as it occurs far more generally in particular seasons of some years
than of others, it is highly probable that a peculiar temperament of
the atmosphere may form a predisposing cause.   It usually makes
its appearance within the first week or fortnight from birth.   The
eye-lids look red, and swell rapidly to such a size that it is difficult
to separate them  without pain.  A discharge of a yellow purulent
fluid soon  succeeds, which, upon opening the lids, will be found to
cover the entire globe of the  eye.  And from the forcible pressure
of lid against lid, both are greatly thickened, and not unfrequently
everted.   The disease  is  usually unconnected  with any other dis-
order; though Mr.  Ware informs us that it is occasionally accompa-
nied with eruptions on  the head and other parts of the body; and
sometimes with signs of a scropulous constitution.
   At the moment of writing this, two infants of highly respectable
families, and who have  had  every possible attention  paid to them,
living  not many doors from each other, are just  recovering from an
attack, which seized them about a fortnight  after birth.   The dis-
charge of  pus or purulent matter was prodigious from each ; both
the eyes of both infants were in great danger: three of the four
eyes were ulcerated on the cornea on the third or fourth day, and
in one of the eyes  the  ulceration spread so  completely over the
pupil,  as entirely and irrecoverably to destroy the sight.  Much of
the best medical and chirurgical advice that this metropolis can af-
ford, including that of ophthalmic surgeons, was had recourse to in
either instance.   The author  was  one" of those consulted  in the one
case, and was privy to the  proceedings in the  other.
   I cannot say that  either in  these or in any  other instance that has
fallen  within my own range of practice, I have  seen all the benefit
from the use  of Bates's powerful, but stimulant astringent, known by
the name of aqua camphorata,  which  Mr. Ware ascribes to it.   1
have known it, at times,  check the discharge, but do almost as much
mischief from the pain it excites, and the  irritation produced by
very long fits of restlessness and crying, which is sure  to follow.  In
consequence of which, moreover, neither the mother nor the nurse
can summon  fortitude to use it half so often or half so effectually as
they ought:  and even on this  account alone, I have sometimes been
compelled to relinquish it.  Yet, even where it has had a fair trial,
I have not generally found it successful.
   In most  of the cases, however, related by  Mr. Ware, the inflam-
matidn was less violent than iu those just adverted to, and had con-
tinued for  some  weeks, and assumed  a chronic  character:  and un-
der such circumstances,  this pungent  application  may certainly be
had recourse to  with  more  propriety, and a   fair  expectation of
benefit.                                          ,
  *  Remarks on the Ophthalmy, Plorophthalmy,  and purulent Eyes of new-born
Infants.  Edit. Tec. IS 14. 
286
HjEMATICA.
[CL. III.—OR. II.
   The plan that has proved most effectual, in my own course of ob-
servation is,  to syringe  the eyes thoroughly, so that the  whole  of
the purulent discharge may be  washed out, with a solution of alum
in water, in the proportion of not less than a grain  to an ounce:  to
continue this syringing three times a-day, to keep the bowels open,
scarify the  gorged vessels of  the conjunctiva where it can be done,
apply leeches to the temples and surround the forehead and temples
lightly and  loosely with  folded linen, wetted  with a lotion of an
ounce of the liquor ammoniae acetatis mixed with seven ounces  of
water, and  kept cold in  a bucket of ice.  The child, in order to re-
ceive the full benefit of the solution of alum, should have  its head
laid flat between the  knees of the operator, with the  face uppermost:
the lids should be separated from each other by the  fingers, or if ne-
cessary,  as  it almost always is, by the assistance of a blunt silver spa-
tula, or some other blunt  instrument, and the  point of the syringe
loaded with the astringent lotions should then be  introduced be-
tween them, and convey its contents all around; the  syringing be-
ing repeated till the  whole of the collected matter is washed  away.
The pain produced by the use of this solution is trifling, and the
child ceases to cry almost as soon as the  operation is over.
   If, when  the inflammation begins  to  subside, an ulcer is detected
on any part of the cornea, and especially if it be  over the pupil, a
solution of nitrate  of silver, in the proportion of a grain to an ounce
of water, should be dropped into the eye night and morning after the
syringing is over, and the eye be kept  Open  for about half a mi-
nute, so  that the  solution  may not be wiped away suddenly by the
closing of the lids, but may fairly lie upon the ulcer and float over
it for this period of time.   Extract of bark should also be given dis-
solved in a small quantity of  water, to  as great an extent as the in-
fant can be made to  swallow  it; and if  looseness be produced,  it
should be checked by a drop  or  half a drop  of laudanum in each
draught.  Prussiate of potash is also a  very good astringent for con-
tracting the area of the ulcer, and expediting the healing process;
and may be used  instead of the solution  of the nitrate of silver iq
the form of an ointment, by means of the unguentum cetacei.  By a
careful perseverance in this process  I  have not  only seen  ulcera-?
lions on the cornea heal speedily, but in one or two instances, with-
out leaving any cicatrix to impede the vision, even where the ulcer
ration has been seated over the pupil. 
GE. V1II.-SP. IV.]    SANGUINEOUS FUNCTION.
                        SPECIES  IV.

         .  OPHTHALMIA GLUTINOSA.

                  ©flnttnons (©jmtnalmg.

THE INFLAMMATION CHIEFLY SEATED ON  THE TARSUS, OR EDGES OF THE
  EYE-LIDS ;  ITS  SEBACEOUS  GLANDS SECRETING A  VISCOUS AND  ACRID
  FLUID THAT GLUES AND ULCERATES THE  EDGES,  AND  IRRITATES THE
  EYE.

Thts is the psorophthalmia of Plenck and Mr. Ware; and consists
in an inflamed state of the small sebaceous glands, whose ducts ar-
ranged in a row on the edge  of each eye-lid,  pour forth a viscid
matter that incrusts and hardens; and, during sleep, when the lids
have been for some time in contact, glues them  together so firmly,
that they cannot be separated without many a painful effort.   This
matter, instead of being mild and lubricant, as in health, is now not
only viscid but acrimonious and erosive ; whence the eye is irritat-
ed, and the edges of the lids ulcerated; and the  complaint is apt to
become chronic, and will sometimes  last for years, or even for life.
  The disease  is  not unfrequenfly  produced  by  small pox and
measles;  occasionally by a taraxis or common lachrymose ophthal-
my from cold or any other causes,  and in  a few instances, though
rarely, from a sty. Sometimes it appears to be the result  ofaschro-
phulous or venereal taint.
  It is  best attacked, and perhaps  only to  be cured by such  local
stimulants as may excite a new action or inflammation that  may be
more manageable.   The  practice  of M.  St. Yves was here  very
bold; he touched the ulcers on  the edge of the eye-lid  with lapis
infernalis, and thus cauterized  the  morbid surface.   The unguen-
tum hydrargyris nitratis, or the older  form entitled  unguentum hy-
drargyris oitrati, has of late been used with equal success, and with
far less danger of injuring the ball of the eye ; and if the  inflamma-
tion have spread from the tarsus to the ball  itself, this also  may be
illined  with the same application.  The. best way of using which is
not that of a pencil-brush, but of letting a drop  of it fall into the
eye, melted for the purpose in  a small silver spoon held over a can-
die.  Or a drop of spirits, as vinum opii, ether, or Riga balsam may
be allowed to fall into the eye in the  same manner, and be repeat-
ed daily.
287 
288                     HJEMATICA.           [CL. HI-OR. II.


                        SPECIES  V.

             OPTHALMIA LIPPITUDO.    ■

                         JLippitutit.

EYE WEAK AND WEEPING, WITH SLIGHT BUT CHRONIC INFLAMMATION ; TARSUS
  THICKENED, SOMETIMES EVERTED, WITH A  PERMANENT REDNESS ON ITS
  EDGE.

This species is usually a relic  or  sequel of some one of the pre-
ceding, in  consequence  of ill-treatment  or neglect;  and may be
contemplated under two varieties :
x Simplex.             The edge of the tarsus red, thickened, and
  Blear-eye.             highly irritable,  but without eversion.
/3 Ectropium.           The upper or lower tarsus everted, and the
  Everted  eye-lid.        conjunctiva exposed, and turgid, with red
                         vessels.

  The blood-vessels visible in that part  of the conjunctiva which
covers the  inside of the eye-lids, are far  more numerous than those
observable in that part of it which covers the globe of the eye.
And hence  the  reason  that  in various  species of ophthalmy the
interior of the eye-lid is peculiarly apt to become turgid,  and very
highly inflamed ;  and, from turgescence,  thickens at  its edges, and
is often so considerably everted as to expose a very large portion of
the conjunctiva.  And if these effects of inflammation be not duly
attended to, both the thickening and eversion are apt to remain and
become' permanent; nor is  this  all, for  the exquisitely  tender
membrane  of the eye-lid, constantly exposed to irritation from cold,
sharp winds, dust, a strong light, and excoriating tears, increases in
tenderness, is never free from some degree of inflammation,  and at
length becomes highly vascular, florid, and carunculate, and exhibits
a very hideous deformity; the inverted eye-lid sometimes adhering
and being cemented to the cheek by abrasion and the inosculation of
new vessels.
  The disease,  under  both varieties,  is  the result of debility.
In the commencement of the simple blear-eye or vascular turges-
cence, the vessels should first be scarified with a lancet so  as to
be disgorged of the blood with which they are loaded; and  it will
be  sometimes expedient to repeat the scarification several  times,
for the operation itself produces  a  new and more healthy action,
and gives a disposition to contractility.   The  edge  and interior of
the thickened tarsus should then be attacked with gentle  stimulants
and astringents ; as cold or ice-water, a solution of alum, zinc, lead,
or  camphor; illinations with the best brandy, vinum opii,  or the
nitric oxyde of mercury, in the form of the  college ointment, or any 
GE. VIII.-SP. V.]      SANGUINEOUS FUNCTION.              289

of the other stimulants enumerated under the last species.   Repeated
blisters to the temples have also been very generally recommended;
but I  have frequently  found  them entirely ineffectual.   Where
additional secretion from a neighbouring organ is desirable, it may
be obtained more successfully  by the use of the thymalaea Monspe-
liaca, or spurge-flax, the daphne  Cnidium of Linneus.  Small circu-
lar pieces of its bark, soaked for  about an hour in vinegar, may be
applied to the  temple of the affected side,  and  renewed every ten
or twelve  hours.   It excites a serous discharge, and consequently
produces increased action without blistering or irritation.
  The second variety, or everted eye-lid, is only to be cured by a
surgical operation.  Professor Scarpa was in the habit of destroying
the conjunctiva at the edge of the tarsus with caustic;  and, where
the disease  had made a greater progressf of extirpating the  whole
fungus close to the external muscular substance of the eye-lid, with
the curved  scissors: and Mr. Ware* pursued the practice in many
cases with success.  But where the eversion is considerable and the
tarsus much elongated,  a  simple  excision of the prurient growth is
rarely sufficient to effect a radical cure ;  and M.  Scarpa himself, has
admitted  as mach by  regarding such cases as almost incurable.
The ingenious plan proposed by Sir William  Adams, seems, however,
to have triumphed over even this difficulty, and to have succeeded
in some of the worst and  most  obstinate  cases.  It consists, first, in
removing^ the  whole of the  fungous  growth, by  a small  curved
bistoury, next, in stripping away  a piece of the edge of the tarsus
in the form of the letter V; afterwards in separating  the  eye-lid
from the cheek whenever it adheres to it;  and, finally, in support-
ing the lid, now raised into its  proper place, and confining the
edges of the cut eye-lid,  brought in a state  of juxta-position, by a
proper  bandage.t  The divided  edges heal by the first intention ;
and the cure is often completed in a fortnight, with a restoration of
the eye-lid to its healthy form.
  An inversion or entropium  of  the organ  is sometimes  produced
from a  contraction of its internal  membrane in consequence of a
cicatrix, or from other causes.J   The hairs of the  eye-lashes prove
a great source of irritation : but the disease may be removed  by
some of the means just described.

     *  Remarks on the Ophthalmy, &c. p. 40.
     t Practical Observations on Ectropium, i&rc. Chap. i.
     X Planner, De Vulneribus superciliis illatis. Opusc. Tom. n.
VOL. II.
37 
290                     H.EMATICA.            [cl. ih.-or. ii.



                      GENUS  TX.

                      CATARRHUS.

                          Catarrh.

INFLAMMATION  OF THE MUCOUS MEMBRANE OF  THE FAUCES, OFTEN  EX-
  TENDING TO THE BRONCHIA, AND FRONTAL SINUSES ; INFARCTION OF THE
  NOSTRILS ; SNEEZING J AND, FOR THE MOST PART, A MUCOUS EXPECTORATION,
  OR DISCHARGE FROM THE NOSE.

Catarrh is a Greek compound, and imports " defluxion," from kxvx,
denoting, as  stated  in the table  of significations to the affixes and
suffixes of medical terms in the Nosology, " augmented action," and
feu, " to flow."  Catarrhus, however, like  ophthalmia,  has been
used in various senses and latitudes by different authors.  Schneider
and Hoffman show a disposition to  extend it  to inflammation of the
mucous glands in general; and Parr, enticed  by such an example,
has made it a genus for including not only what is commonly under-
stood  by catarrh,  but the cough of old  age,  (which he admits is
without pyrexy,) croup, dysentery,  phthisis, cystirrhoea, leucorrhoea,
gonorrhoea, and one or two others.   This  is the widest acceptation
of the  word.   The narrowest is that of the old pathologists, who
thus distinguished between three  separate  terms  which  are now
regarded by many writers as synonymous :

          Si fluit ad pectus, rlicatur rheuma Catarrhus ;
          Ad fauces, Bronchus ; ad nares, esto Coryza.

This couplet is,  perhaps, founded upon Galen's account  of these
affections; but it does not follow up the  Greek  distinction into all
its ramifications ; for the Greek physicians, as Galen himself tells us,
had also  a further supply of names for the defluxion when it fixed
itself chiefly in other parts  of the  neighbourhood'; as acinus, when
the uvula was  the seat  of affection; antiadje,  when  the tonsils;
and paristhmia, when the attack was common to the fauces.  For all
these Celsus employs the Latin term gravedo, between which, how-
ever, and coryza he observes  that there  is a manifest difference.
It  s this difference which I  have endeavoured to support in the
present system;  in which coryza, treated of under our second class,
as an affection of the vocal avenues,  is made to mport nasal defluxion
without pyrexy.  Celsus takes no notice of the term catarrh ; for in
his day catarrh was changed by the later Greek  writers into catas-
TAGMUS.
  Sauvages has only deviated from the rule  contained in the above
Latin  couplet by omitting bronchus and employing catarrhus in its
stead, and rheuma in the stead of catarrhus ; so that with him rheuma 
GE. IX.]
SANGUINEOUS FUNCTION.
291
imports a cold, or febrile defluxion of the chest; catarrhus, the
same affection of the fauces, and adjoining organs; and coryza, the
same malady of the head or nostrils.
  Cullen has regarded rheuma, coryza, bronchus, and catarrhus as
synonymous terms, scarcely indicating varieties of the same disease.
The arrangement of Dr. Cullen, moreover, did not allow  him to
place bex, tussis or cough, any where else ; and being  obliged to
yield to the force  of necessity, he has made cough also a synonym
of catarrh, and has treated of it under this genus.  It is here the
present system differs from Dr. Cullen, as it does likewise in sepa-
rating coryza from the  list  of phlogotic affections.  Cough is not
necessarily  a pyrectic  or inflammatory disease, though it  may be
occasionally a symptom of such disease.   Cough therefore, under
the Greek term bex, we have already considered as well as  coryza,
under the second or pneumatic class ; where they will  probably be
allowed by  most  nosologists to occupy  more  correct and natural
posts than in the present place.  Catarrh, thus explained, embraces
the two following species :
       1. COMMUNIS.            COLD  IN THE HEAD OR CHEST.
       2. EPIDEMICUS.           INFLUENZA.
 Under neither of these  species can catarrh be regarded as a danger-
 ous or very serious disorder, unless neglected or treated improper-
 ly ;  or unless it occurs with great severity in  persons of  delicate
 lungs  or  possessing a consumptive diathesis ; in all which cases its
 result may  be very mischievous, and  lead on  to pneumonitis,  bron-
 chitis, phthisis, or dropsy of the chest, though in itself, and separate
 from such concomitants, by no means  alarming.
                         SPECIES  I.

             CATARRHUS  COMMUNIS.

               <£oUr tn  the i^caTr or <£nest.

          FEVER SLIGHT ;  MUCOUS DISCHARGE CONSIDERABLE.

This is the pose of old English writers, a term precisely synonymous
with the gravedo of Celsus, which is  also employed in the earlier
medical works of our own country.   To pose is still used in the sense
of to stupefy, and the real meaning of posie is a " narcotic charm,"
and  hence a nosegay of  tranquillizing odour inducing repose or
sleep.  The common symptoms of this species are a sense of fulness
in the head, and of weight over the eyes, which are inflamed and
lachrymose.  The nostrils are obstructed,  and pour  forth a thick
acrimonious ichor, which excoriates the skin as it descend, accom- 
292                   HiKMATICA.              [CL« I»'-°R- «•
panied with  frequent sneezing.  The voice  is hoarse, the fauces
sore, and the lungs loaded, often producing a troublesome cough.
  Its usual cause is suppressed perspiration from cold;  whence Dr.
Cullen conceives that cold is the constant and only cause, and would
in every case be detected to be such,  were men  acquainted  with,
and attentive to the circumstances which determine cold to act upon
the  body.
  From the similarity between  the fluid exhaled from  the skin and
that from the lungs, he conceives, that, whenever the former secre-
tion is  obstructed in its flow, it is transferred to, and passes off with
the  latter; the cough being produced by the stimulus of the increas-
ed action, and exhalation.
  There seems, however, to be, in  many cases at least, something
more than this ;  for neither <y)ld nor  suppressed  perspiration will
account for every instance of common  catarrh.  There are few
practitioners, perhaps, but  have sometimes known persons thus af-
fected who have been bed-ridden from chronic lameness or some other
cause,  and have had their chamber warmed night and day by a fire.
Some ladies always catch a cold in the head  on quitting the town
for  the country ;  and others on  quitting the country for  the town.
Something must therefore depend on the actual state of the constitu-
tion at  the moment; and something upon the variable quality of the
atmosphere :  and a change in both frequently perhaps concurs  in
producing the affection of a common catarrh.
  Where the attack is slight, medical  aid  is not often sought for or
needed.  A few days of domestic repose  in a  warm but not a close
atmosphere,  diluent  drinks, with an abstinence from  animal food,
and vinous or other  fermented  liquors, a sudorific posset at night,
with an additional blanket  thrown over the bed to encourage per-
spiration,  usually succeed  in  carrying off the  complaint.   But if
there be a sense  of  oppression  on the chest, or of fulness in the
head, with the  ordinary signs of fever, venesection should be had
recourse to, and a smart purgative immediately afterwards, while
the preceding process is still  continued.  If the cough  should  be
troublesome  at night, it  will be best allayed  by a  dose of Dover's
powder,  which will take off the irritation, and determine  to the
surface.
  Catarrh is also found occasionally, as a symptom, in measles, small-
pox, worms, dentition, and rheumatism. 
GE. IX.-SP. II.]       SANGUINEOUS FUNCTION.              293


                        SPECIES II.

            CATARRHUS  EPIDEMICUS.

                          Enflnen^a.

THE ATTACK SUDDEN ; GREAT HEAVINESS OVER THE EYES ; FEVER STRIK-
                   INGLY DEPRESSIVE ; EPIDEMIC

This species differs chiefly from the preceding in the abruptness of
its incursion, the severity of its symptoms, and very generally in
the rapidity of its transition.  It probably also differs in the nature
of its remote cause, which we shall briefly inquire into after attend-
ing to its diagnostic  character.
   It commences, according  to Dr. J. C. Smith, who has accurately
given  us its pi ogress  as it appeared in 1781 and  1782, with  the
usual  catarrhal symptoms, in conjunction with others that are far
more distressing to  the patient, and often not less  alarming to the
 physician ; such as great languor,  lowness and  oppression at the
 praecordia;  anxiety, with frequent sighing, sickness, and  violent
 head-ache.  The pulse  is  peculiarly  quick and irregular, and at
 night  there is often delirium.   The heat of the body is seldom con-
 siderable, particularly when compared  with the  violence of the
 other symptoms; the skin is  moist, with a  tendency to  profuse
 sweating; the tongue moist, but  white  or yellowish.  Sometimes
 there  are severe muscular pains general or local;  at other times,
erysipelatous patches or efflorescences on different parts of the body,
which, in a  few rare  instances, have  terminated in gangrene  and
death.   From  the  onset, for the first  twenty-four or forty-eight
hours, the symptoms  are extremely violent, far beyond the danger
or duration  of the  distemper.  For the most part it attacks  the
healthy  and robust;  children and old people either  escape entirely,
 or are affected in a slighter  manner.  Pregnant  women, however,
 are disposed to miscarry,  and the flooding is in some cases fatal.
 Patients also subject to pulmonic  complaints suffer  much from the
 cough, difficulty of breathing, and other  peripneumonic symptoms,
 which occasionally lead on to dissolution.*
   Such is the general progress of influenza in most of the periods
 in which it has shown itself.  But in  every  period  its  symptoms
 have considerably  varied  in  severity in different  individuals.  In
many instances, they have scarcely exceeded the signs of a  common
cold ; in others, the pleuritic pain has been very acute, or the head-
ache intolerable, shooting  up to the vortex with a sense  of split-
ting ; the pulse has been  a hundred and forty, and often considerably
more, in a minute, with incoherency or delirium from the first night.
* Medical Communications, Vol. i. p. 71. 
 294                    H/EMATICA.            [CL. HI.-OR. II.

 Yet cases of real danger are very few; and the violence of the  dis-
 ease is over frequently in forty-eight hours; sometimes in  twenty-
 four.  Those  who  have suffered  appear to be  insusceptible of a
 second attack  during the continuance of the epidemy, though they
 have no indemnity against  the next  that may  appear.  In many
 cases,  however, the general debility induced on the system does not
 terminate with the catarrh itself, but remains for weeks, perhaps tor
 months afterwards, and is sometimes removed with great difficulty.
   The disease has been known and described from the time of Hip-
 pocrates to the present day : and is dwelt upon at great length by  Sy-
 denham, who regarded it in the autumn of 1675 as a general cough
 produced by cold and  moist weather, grafted upon the  autumnal
 epidemy, and  varying its symptoms ; whence the fever, which had
 hitherto chiefly attacked the head or the bowels, now transferred
 its violence to  the thorax, and  excited symptoms  which had often a
 semblance to those of genuine pleuritis, but in reality were not so,
 and demanded  a different and less  evacuant treatment; the patient
being  uniformly made  worse  by copious and  repeated bleedings;
though a  single  moderate venesection was often  useful,  and in a
few  instances  a second; beyond which Sydenham always found it
mischievous to proceed.  And in proof that this was the real nature
 of the case, he observes, that, " these catarrhs and coughs continued
 to the  end of November, after which they abated, but the fever still
remained the same as it was before the catarrhs appeared ;" meaning
 that it  then returned to its essential character:  " although,"  he con-
 tinues, " it was neither  quite so epidemic, nor  accompanied with
quite the same symptoms; since these incidentally depended upon  the
 catarrhs."
  Influenza, however, as we shall have occasion  to shew presently,
 has not only occurred  in the  autumn,  but  in every  season of  the
year, whether  hot, cold,  damp, or temperate;  and when there  has
been apparently  no other constitutional  distemper with which it
 could unite itself.  That it  is an epidemy, cannot be  doubted for a
moment: yet this is to advance  but a very little way towards a know-
ledge of its origin or remote  cause; for  we have still to inquire into
the nature of  epidemies, their sources, diversities,  and  means of
 diffusion ;  often, as  in the case  of spasmodic cholera,  in the  very
 teeth of periodical winds and other meteorological phenomena that
we might fairly conclude, if  we did not know  the contrary, would
irresistibly oppose their progress, or disintegrate their principles,
 and consequently abolish their power.  Dr. Sydenham,  with  the
 modesty which  peculiarly  belongs to  himself, and always  charac-
 terizes real knowledge, freely confesses his ignorance upon the sub-
 ject, though he is rather disposed to ascribe them to  "some occult
 and inexplicable changes wrought in the bowels of the earth itself
 by which the atmosphere becomes contaminated  with certain effluvia
 which  predispose the bodies of men to some form or other of dis-
 ease ;" while  Hippocrates, who had pursued  the same  recondite
 subject with the same indefatigable spirit upwards of two thousand 
GE. IX.-SP. II.]
SANGUINEOUS FUNCTION.
295
 years before, resolves them with a devotional feeling  which would
 do honour to the  philosophy  of  the  present  day, but  which  the
 philosophy of the present day  has not always evinced, into a  pre-
 sent divinity, a providential interposition; for such, as Galen informs
 us, is the actual meaning of his TO 0EION,* and not some unknown
 and latent physical principle of the atmosphere, as various exposi-
 tors have conceived : " non enim quaecunque causas habent incogni-
 tas et abditas divina vocamus; sed ubi admirabilia videntur  dun-
 taxat."t
   An epidemy, however, or state of the atmosphere capable of pro-
 ducing  any general disorder, whether originating specially or in the
 ordinary course of nature, may depend upon an intemperament, or
 inharmonious combination of the elementary principles of  which it
 consists, or upon some foreign  principle accidentally combined with
 it, and  which has of late years more especially been called a miasm
 or contamination.  It is possible that both  these may be causes of
 different  diseases; and, in  this case, the term epidemy might be
 more correctly limited to  those  which issue  from the  first cause
 than from the second : and Dr. Hosack has endeavoured thus to limit
 it.  But as it is rarely that  we can distinguish between the  two,  and
 especially as the term has been very generally applied to diseases
 arising from both sources, it is not worth while to alter its common
 signification.
   In the disease before us, many writers have endeavoured to trace
 it to the first  of the  above causes, and particularly  to the atmos-
 phere's being in a state of negative electricity ;  and M. Weber, fully
 confiding in this cause,  has  recommended, somewhat  whimsically,
 the use of socks made of the most powerful non-conductors, as  oil-
 ed-silk,  or paper covered with sealing-wax, as a certain prophylac-
 tic.f  Others, without undertaking to determine in  what the atmos-
 pheric intemperament consists, have regarded it as  a mere  exciting
 cause of catarrhs, or, in other words, as merely rendering the body
 more susceptive of the  ordinary causes of this  disease,  and hence
 converting a sporadic into a general distemper.
   More commonly, however,  catarrh  as well as other epidemics
 have in modern times been contemplated as  dependent upon the se-
 cond of the aerial causes just adverted to, namely, the existence of
 a specific miasm, or morbid principle of a peculiar kind into  the
 atmosphere, distinct from any change in the combination of its pro-
 per elements.§   There is much, indeed, to support this opinion ;  for
in many cases, as in intermittent and remittent fevers, we can mani-
 festly trace such an origin; and, as we have already shown that
  * De Prognost. Lib. i.
  t Comment, in Progn. Hipp.

1787Ralm* B"efwachsel> mit seil,e» chemaligen, Schiilern. Band. 11. Zurich, 8vo.


^ledf%uTi^7a318!rpD;vMertenS °bSerV' Med' T°m- "• 4" and Simmons' ''""d- 
296
HiEMATICA.
[CL. IH.-OR. H.
contagions and  miasms are often identic or nearly  so, the former
may be brought forward as abundantly confirming the same view.
   This identity, or approach  to  identity, between  contagions and
miasms, is closely connected with the present subject,  and must be
a little examined into for its clearer elucidation
   In treating of the  origin and laws of febrile miasm, we observed,
that it is of two  distinct modifications, or proceeds from two distinct
sources :* that in its ordinary course, it first  appears as the  result
of a  decomposition  of dead  organized matter  operated upon by
the common auxiliaries of putrefaction : but that aiterwards,  "dur-
ing the action of the fever thus produced, the effluvium from  the
living body is loaded with miasm of the same  kind,  completely ela-
borated as it passes off, and standing in no  need  of  the  decomposi-
tion of the effluvium for its formation ; under which form it is com-
monly known by the name of contagion."
   1 may now add, that as primary febrile miasm  is not the only mi-
asm generated in the atmosphere, so it does not seem to be the only
miasm that gives rise to contagion :  that both are  very numerous
in their kinds, and that specific contagions are, though perhaps  not
always, yet far most  generally, a result of specific miasms produced
as above.   This seems especially to be  the case  in  respect to influ-
enza ; for though most individuals labouring under it  are evidently
affected from an atmospheric taint, many, as we shall show present-
ly? appear, as in the  case of remittent or typhous fever,  to receive
it from personal contagion: nor is there, in fact,  any reason why  a
puriform discharge from the mucous membrane of the nostrils may
not be contagious,  as well as a puriform discharge from the mucous
membrane of the eye-lids in opthalmy, or from the  urethra in ble-
norrhoea, or, as we shall shortly have to notice, from the rectum in
dysentery.  Among dogs and horses we perceive the same  disease,
in many instances highly and extensively contagious, and accompani-
ed with so violent a degree fever as to be peculiarly dangerous, es-
pecially to the young of these kinds.   In South  America, in  parti-
cular, this affection is so violent that half the dogs pupped there are
supposed  to  die of it  while  sucklings.  Whence in  common lan-
guage it is called emphatically the distemper,  though vulgarly  the
snaffles, or rather snuffles, from the state of the nostrils.  In nosolo-
gy it is commonly called catarrhus caninus.
   Generally speaking, specific miasms  and contagions  capab't  of
affecting one kind of animals, are incapable  of affecting any  other
kind; or at least rarely extend their  influence any further.   In  a
few febrile pestilences, quadrupeds and birds  seem to  have been
fellow-sufferers with mankind, as we have already  had occasion to
notice under epanetus malignus, or malignant remittent fever.  But
this is not common ;  and in some instances is well  known to have
depended upon the general dearth of a country, or the insalubrity
of the preceding harvest.   A few of the exanthems,  as cow-pox, arc
* Class n. Ord. I.—Remote Cause of Fever. 
GE. IX.-SP. II.]        SANGUINEOUS FUNCTION.             297

capable of propagation from one species to another; but the great-
er number of them are not, or only with  great difficulty.  When  a
putrid fever has broken out among a ship's crew, the live stock has
never been known to suffer from it: and it has happened occasionally,
when large numbers of sheep  and hogs have been stowed in a ship
for the purpose of exportation, sometimes  the former have been at-
tacked with infectious fever, and sometimes the latter; but the sheep
have  never communicated it to the hogs, nor the hogs to the sheep,
nor either of them to the ship's crew.  " It seems to be a general
law of nature," observes Sir  Gilbert Blane, " at least  among the
mammalia, that accumulation  and stagnation of the exhalations of
the living body produce disease.  The glanders of horses arise only
in large stables, and  the distemper of dogs in kennels.  During the
American  war,  it was proposed to send  live sheep from England
across the Atlantic.   In  a few  weeks, in  consequence of being
crowded in a ship, they all died of a febrile disorder."—" In the ex-
pedition to Quiberon in  1795, several horse-transports had their
hatches shut  for a length of time in  a storm, by which  means eight
horses were  suffocated.   Those which survived became affected
with  the glanders soon after they  landed.  Professor  Colman saw
twenty of  them under this disorder; a considerable number  had
been  previously destroyed.*  It does not  appear  that  in either of
these instances, the respective disorders were communicated from
one genus  or species of animals to another.
   That the catarrh before us possesses not only an epidemic charac-
ter, but is  dependent on  atmospheric influence, is established b^
such a cloud of well  known proofs, that it is hardly worth while to
give examples.  Of a dozen persons in perfect  health in the  same
room, ten have often been attacked as nearly as possible at the same
time.   In the influenza of 1782, three families, consisting of seven-
teen persons, arrived on  the same  day at an hotel in the Adelphi
all in  perfect  health.   The next day they were all affected  with
the symptoms of the  reigning  disease.!  In an  hospital, containing
a hundred and seventy  persons, more than  a  hundred were, on  one
occasion, attacked within  twenty-four hours ; and few of the remain-
der escaped afterwards.
   We have said, however, that the middle-aged, the strong, and the
robust are affected soonest, and suffer most severely, while the young
and the old are less  susceptive of its influence.   In  proof of this,
we may advert to the fact, that healthy and well disciplined soldiers
suffer peculiarly.  In  1782, this was especially  the case at Aber-
deen : at Dublin there were,  at the same period, seven hundred
soldiers confined under it  in their barracks at  once, and  incapable
of doing their duty ;| while at Utrecht the number amounted to
not less  than three thousand.  On the contrary, out of seven  hun-
       ■'* Med. during. Trars. iv. 89. 4T;».
       t Med. Trans. Vol. in. p. 59.
       X Dr. Hamilton, Mem. Med. Poc. of I.ond. l?f!2.
or..  II.              ?,P. 
298                    HvEMATICA.            [<*• m.-c-R. «

dred boys in Christ's Hospital, during the same epidemy, only four-
teen had the disease, and all of them in the slightest manner.
  The proofs of communication by personal contagion  are not less
decisive.  " The first," says Dr.  Hamilton, describing the influenza
of 1782, "who were seized with it at Norwich,  were  two men
lately arrived from  London, where  it then continued to rage.   A
Serjeant of grenadiers in the 10th regiment of foot  went to London
on  furlough : the disease then raged in the capital.  He returned,
in a few days, to St. Albans, affected,  and communicated it  to the
people in whose house   he  had his billet.   This was the first of its
appearance there :  and from thence it  spread rapidly  all over the
town."!
  Dr. Cullen, in his Synopsis,  has followed the more striking re-
turns of  influenza from the fourteenth century down to the  present
times ; or rather from  the Cronica Meteorologica Toscana of 1323,
by Targioni Tozzetti to Saillant's Tableau des Epidemies catarrhales.
""in all these instances," says he, " the pbaenomena 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 sehlom  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  afterwards,  was preceded by  weather  uncommonly warm;
while  in that of 1767, being the  next in  rotation, which was also
 very severe though productive of less durable mischief to the con-
 stitution, the weather  was remarkable  for being unusually cold.J
 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 ; whence it crossed
•  .Med. Trans. Vol. HI. p. 56.
t Mem. Med. Soc. of Loud, ut supra.
X Dr. Heberden, Med. Transact, i. Art. xvm, 
GE. 1X.-SP. II.]
SANGUINEOUS FUNCTION.
299
the Atlantic, and  arrived  the  ensuing year  in  America.  But this
assertion wants confirmation.   If we allow its  materies to depend
un*>n 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 highest degree of agitation by tempests.  Of the specific miasms
we 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 con'iaed  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 the 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 we have already observed,  is rarely required, and, from the  de-
 bility so soon  induced,  should be avoided, except in urgent pleuritic
 pains, which  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 perspiration which Chenot has distinguished by the name
ofdipnoe, 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 which, 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 powder  in all  catarrhal affec-
 tions, asserting that there is  no disease in which  opium  has been
 found more  useful.!  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:  an.I, 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. n. p. 53.
 Mat. Med. Part n. Ch. v\. 
300                     HiEMATlCA.            L«- I«-°R- U'

cold bathing, or been augmented by the practice, as^in^"^h^
rarelv  terminated in  phthisis; and, according  to  Dr. Carmicftaei
Smith, is less disposed  to  produce this  complaint  than a common
catarrh.
                     GENUS   X.

                     DYSENTERIA.

                 Bgaenterg.  Elooty) if Utj.\

INFLAMMATION OF THE MUCOUS MEMBRANE OF THE LARGER  INTESTINK3 ;
  GRIPING  AND TENESMUS ;  FREQUENT AND  OFTEN  BLOODY DEJECTIONS J
  THE FECES SELDOM DISCHARGED, AND  IN SMALL QUANTITIES.

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?
   Dr. Cullen, who, if he did not first start this controversy,  has fol-
lowed it up  with a more peremptory opinion than perhaps any
other writer, has contended for the  negative of the question ; and
has hence not only arranged the disease under his  class pyrexiae,
but generically distinguished it by the character of pyrexia contagio-
sa : asserting, in his  Synop>is, 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 andDr. Young make a nearer  approach to  the  general

           ;* Part i. Book v. Chap. n. Sect, mlxxv. 
   (SE. 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  to be 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  we cannot do  better than turn  back our
   footsteps to  the minute and accurate description of Sydenham, and
   take him as our pole-star: under  whose clear guidance we shall
   seldom  fall into error, and whose view of the subject has  best har-
   monized with whatever degree  of practical  information has fallen
   to  my own 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 dysenterica."
     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 well 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 acces-it, nunc aberat.   " At times," says he, " the dysente-
   ry commences with rigor and shivering, succeeded by a heat of the
   whoie body, as  is the case  in fevers—but frequently there  is no ap- 
302                     HiEMATICA.            [CL.  IH.-<
pearance of fever, for the host of gripings take the lead, and the de-
jections follow."  He pursues his description of the simple dysentery,
or that without fever, observing that in this species an excrementi-
tious stool 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 with
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  epide-
mic ;  the one  of a milder nature without fever, the other of a ma-
lignant 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 writing the above, the author has met with Dr. Harty's " Ob-
servations on the Simple Dysentery and  its Combinations, contain-
ing a review of the  most celebrated authors who have written on
this subject:" in which much of his own opinion is confirmed, and
copiously illustrated.
  It is only necessary to  observe further, that though there may he,
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,
which 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 diseases;
though, from too close an adherence to the concurrent arrangement
of the earlier nosologists, it will be found placed, in  the physiologi-
cal synopsis, under the order enterica of the class Cceliaca,  a posi-
tion which 1  now beg the reader to correct.
  The febris nova or dysenterica of Sydenham seems hardly entitled
to consideration as a distinct  species.  It was the common epidemy
of the  season, accompanied  with or succeeded  by a  few  of the
slighter 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.         SIMPLE DYSENTERY.
2.----------PYKECTICA.       DYSENTERIC FEVER. 
HE. X.-SP. I.]      SANGUINEOUS FUNCTION.               303


                        SPECIES I.

              DYSENTERIA  SIMPLEX.

                    Stmjrtc B^mntoxs.

FEVER SLIGHT OR UNPERCETVED ;  THE  FECES, WHEN DISCHARGED, EVA-
  CUATED 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 which enter into  the generic or specific definition of
the disease before  us; as also how it is possible for these symptoms
lo be combined with fevers of various kinds and  various degrees,
so as to render the complaint  peculiarly complicated and dange-
rous ; though we have not  yet been able to find out what are  the
precise  causes that,  operating  locally,  produce  the  distinctive
symptoms of dysentery Tather than  those of diarrhoea,  cholera, or
any  other irritation or spasmodic  action of the intestinal canal.
This may, perhaps, sometimes depend upon idiosyncrascy, some-
times upon accident, and, in the severer cases,  upon contagion or a
specific miasm.
  The symptoms,  however, 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 arc  dejected, the existence of  spasmodic constriction in
or about the colon or the upper part of the  large intestines.  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
v Nat. Med. Part. hi. p. 294—826.
t Cawley, Lond. Med. Journ. 1786. 
304
I-OEMAT1CA.
[CL. III.-OR. II.
 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  flow of bile, often of a deeper
 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 usual 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 dysenteriaz: 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.t
   The ordinary  exciting cause of simple dysentery, there can be
little question 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 aestil al 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
power, 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
w Discourssur la Nature, &c. des Maladies accompagnees de Dysenterie.
t Amaen. 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 of
 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 mucous, 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,  mucous, and  accompanied with
 gripings, the  disorder may as justly be called a  dysentery as if
 blood were intermixed with 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 venesec-
 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 depressioh 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, 1 allow any temperate cardiac to be taken  occasionally in
compound scordium or some  other distilled water,  through the
 whole  course of the disease."
  For  common drink he prescribed milk and water, or the  white
decoction, with crumb* of bread, or  posset-drink;  and where  there
  VOL.  II.                   3f> 
306                     ILBMATICA.           [«. ™-OR. II.

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

 '"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 which 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 sufficient-
 ly 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 prima? 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 dysentery 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 stiil better,  with some neutral salt and ipecacuan, as
 iu the  admirable composition of Dover's powder.  And with these
 few alterations it would be difficult, perhaps, to improve upon the
 plan laid down 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
  -peed; and the sick room be large,  and freely  ventilated.
* Sect. iv. Cap. in. passim. 
<JE. X.-SP.  II.]       SANGUINEOUS  FUNCTION.              307


                        SPECIES  II.

            DYSENTERIA PYRECTICA.

                    Sgstnteric JFefocr.

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: whence 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  with  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 two following varieties, as already laid
down by Dr. Macbride :
  x Caumatodes.        The accompanying fever being a cauma.
  £ Typhodes.          The accompanying feyer  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
•\< the  last,  with so much correctness and strength of colouring by 
S08
H/EMATICA.
[CL. 11I.-OR. II
Sydenham, that  we 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.  " 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 with 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 within 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 progress of 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
with 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 aphtha?  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 noi 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 abraiding 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  bv 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 neaifly 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 was more  violent 
GE. X.-SP. II.]        SANGUINEOUS  FUNCTION.            309

and fatal; for we  are told by this distinguished writer that  pure
arterial blood, to  the amount of several ounces, was  voided in a
stream every half hour, and that some patients bled to death in this
manner; while  others perished, from the severity of the general
symptoms, within 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 acrimonious 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 clustres 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  drawn copiously  and  with a:l
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 typhous from the first, has a general
tendency to pass into this type ; and the intestinal inflammation is
perhaps of the  erysipelatous 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
HiEMATlCA.
[CL. I1I.-OR. II.
  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 power; and on this  account some
have even ventured to advise that the naustja should be maintained
by  a  repetition of the medicine  for some hours.   But  I  cannot
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, how 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 prostra-
tion of strength.   Now, 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,
throws  back the  febrile action to  this quarter, and  produces the
revulsion we 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  which the virulence of the glass is greatly subdued by
its  mixture  with the  wax, has very unadvisedly grown obselete.
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
und 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.
t Bc-.ncrkungen, &c. Band. I. p. 184. 
GF-. X.-SP. II.]         SANGUINEOUS  FUNCTION.             311

state of the stomach,  and  not a little on the idiosyncrasy.   It was
lon°- in the hands of empirics before it found its way into regular
practice ;  and the world is, or ought  to be, much indebted to Dr.
Young for  having first introduced it into professional notice.  The
ordinary dose for an adult is ten grains ; but where the bowels alone
are  intended to  he moved,  or  rather  where the object is not to
excite sickness, it  should  be diminished to six grains; in which
quantity it rarely excites nausea; and upon the whole, in whatever
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 alore ; and we 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 even commenced with 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 may be 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 and
  the acute sensibility of the sphincter frequently render it impossible
  for us to avail ourselves  of their use.
    Opium has also  been applied to the  rectum in its solid  substance,
  in the shape of a small pill or suppository :  but here again it will be
  unadvisable if there be much irritation of the sphincter: fof as a
  bard body, it  will excite more soreness by its pressure than pro-
  duce relief by its narcotic effect; and if the  tenesmus be  considera-
  ble it will be impossible to retain  it.  The only mode in which  1
  have found it useful under these circumstances is, when rubbed into
  an impalpable pulp with a  little of the oil  or  butter  of the cocoa-
  nut, and rolled  up into  small  pastiles of a sufficient  consistency to
  bear the touch. 
312
ILEMATICA.          [CL.  IH.-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 a 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," sy.ys he, " though not incompati-
 ble with, is commonly not favourable to, sweating."  This, howev-
 er, 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 withdrawn 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 woollen covering. Hillary,
in the warmer temperature of the West Indies, obtained a like  ef-
 fect from small doses 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-
vellent as any of those  already noticed, but  which we should not  al-
ways recommend, nor find our patients disposed to carry into  effect.
i; 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."*
'" Zoonom. CI. n. i. 3. 19. 
GE. X.-feP. 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  conside-
rable 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, that 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 if 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.  Odhelius, how-
ever, asserts that  he employed ii 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,  we  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 Richter 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, with 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 Richter 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
  y  K. Lazarettet i Stockholm, &c. p. 27.—Abhandl. dex Schwed. Acad, der Wis-
sensch. Band, xxv__Rese, Diss, de Nuce Vomica. Jen. 1783.
  VOL. II               40 
■H4                     H^IATICA,           [«- nI--°R- H"

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.               ru   ,
  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 Helmont, 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
powerfii  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.
jtet the one or the other of  the above  compounds should be  con-
tinued  without  any alteration in consequence of such a beverage.
   A* the disease declines, there  will often be found  a very conside-
rable degree  of debility, and a chronic  diarrhoea,  with occasional
discharms of blood from the excoriated state 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. tl.]
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 with 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
power 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.t  Of late years, however^ it has again been rising in public
estimation ; and  as a truly valuable tonic, and particularly in intestinal
debilities, I am pleased  to see it taking a stand in the Materia Medi-
ca 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 putre-
scent  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,|  1 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. Animadveis.  Gooch's Cases, &c. p. 421.
  t Mat. Med. Vol. n. p. 79.
  X Monro Edin. Med. Essays, Vol. in. Art. iv.
  $ PercivaJV  K.^ays. n. Hist, de la Societe de Medicine, p. 340. 1776, 
310
HyEMATICA.
[CL. I1I.-OR. II.
for a long time demand peculiar local  attention;  and demulcent
or bland oleaginous injections, as the infusion  or  oil  ot  "nseecl,
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 id
forwarding the expansion of a new cuticle.
   In Ion* protracted and chronic cases, lime-water drunk freely has
occasional^  also proved  useful.   The coat of the  intestinal canal
is  here, however, sometimes very considerably thickened and indu-
rated   And in such cases the best remedy we  can have  recourse
to is mercury.  Houlston recommonds such a course to be persisted
in to salivation.*   Libavius  commenced his mercurial plan  with
mercurii.l ointment.!  Stoll, on dissection, found in several instances
the affected intestines thickened, indurated, rigid, yet without ulcer-
ation ; and sometimes evidently marked with chronic inflammation.}
                      GENUS XL


                       BUCNEMIA.




TENSE, DIFFUSE, INFLAMMATORY SWELLING OF A LOWER EXTREMITY J USU-
  ALLY 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; but 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 :

  1. BUCNEMIA SPARGANOSIS.        PUERPERAL  TUMID-LEG.
  2. --------  TROPICA.            TUMID-LEG OF HOT  CLIMATES.

  As the present genus is  new, it has been necessary to distinguish
it by a new name;  and on this account the author has made choice
of that of Eucnemia, from €«v, a Greek augment, probably derived
from the Hebrew y^ or njQ " to swell, augment,  or tumefy,"  a

                 * Observations on Poisons, &c.
                 t Hornung, Cista, p. 2.
                 t Bat. Med. Part m.  p. 277. 
olE. XI.-SP. I.]
SANGUINEOUS FUNCTION.
317
particle common to the medical vocabulary;  and the Greek noun
itnpn, " crus," or, " the leg," literally, therefore, " bulky or tumid
leg."
                         SPECIES  1.

             BUCNEMIA SPARGANOSIS.

                  ^uerjjcral ftumtu^SUg.

JLHE TUMID LIMB PALE, GLABROUS, EQUABLE, ELASTIC, ACUTELY TENDER J
  EXHIBITING  TO THE TOUCH A FEELING OF NUMEROUS  IRREGULAR  PRO-
  MINENCES UNDER  THE SKIN ;  FEVER, A HECTIC :  OCCURRING  CHIEFLY
  DURING THE SECOND OR THIRD WEEK 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  des-
cribed 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 which express the real nature of the affection, and some of
them  a source obviously erroneous.
  By  Dioscorides it was  denominated sparganosis, from oKx^yxu,
" to tumefy and  distend ;" lumeo et distentus sum, as rendered by
Scapula; and, as the term is sufficiently expressive, it has been  pre-
ferred on the  present occasion to any of the rest; and appropriated
to the present disease, instead of being made common,  as  Diosco-
rides  has made it, to numerous other affections of the chest.
  By  Dioscorides,  and most writers till within  the last  twenty or
thirty  years,  the  swelling has  been ascribed to a redundancy of
milk,  and a morbid deposition in consequence of such redundancy;
* Modern Practice of Physic.  Discaees of the Puerperal state. 
318
H.EMATICA.
[CL. III.-OR.  H.
 whence the French practitioners call it to the present day, after Pu-
 zos, depot laiteux, or 1 ait repandu; and the Germans milchstreichen.
 A minuter attention to the subject, however, has_ sufficiently shown
 that this complaint  has  seldom any connexion  with the milk: per-
 haps never.  It has occurred where the breasts have  been destitute
 of milk, and where  they have overflowed; where suckling has been
 relinquished, and where it has been continued.   It is but very lately
 I  was  consulted by a young woman  labouring under it, who was
 suckling her infant  without any complaint of the  breast whatever.
   It is as little influenced by the state of the lochia as by that of the
 milk.  It attacks women of all ranks and of all habits ; the  healthy
 and the diseased; the lean and the corpulent; the sedentary and the
 active; the young and the middle-aged.   It also occurs at all seasons
 and situations; and has never been  known to  appear in  any other
 part cf the body than the lower extremities.
   In about twelve or fourteen days after delivery the patient com-
 plains  of pain in the groin of one side,  accompanied with the gene-
 ral train  of pyrectic symptoms, but without the precursive shivering.
 The part affected soon becomes swelled and distended, the swelling
 extending to the labia  pudendi of the same  side, and down the in-
 side of the thigh to the leg and foot;  in a day or two the limb is
 double its natural size, is hot, exquisitely tender, and  moved with
 great difficulty.  It has not, however, the ordinary external signs of
 inflammation, but is hard, smooth, glabrous, pale, and equable, except
 where the conglobate glands are situate, which are corded and knotty,
 as in the groin,  the ham, and the back and  fleshy part of the leg.
 There is, occasionally, an uneasiness in the loins and in the region
 of the  pubes  on the same  side.  The swelling has  sometimes ap-
 peared as early as twenty-four hours after delivery,  and sometimes
 not till five  weeks  afterwards.   The  accompanying fever, which
 is of a hectic form, usually declines  about the fourteenth or twenty-
 first day, but in some cases runs on for six or  eight weeks, and the
 patient becomes greatly emaciated.  The first  appearance of im-
 provement  takes place where the  disease  commenced,  about the
 groin,  the pain  and tumor  gradually subsiding in this  quarter, and
 the amendment spreading in a continuous line.  Sometimes, though
 rarely, both sides are affected simultaneously,  and, in a few instan-
 ces, the  sound leg has exhibited something, though a less degree,
 of the same  complaint, as the diseased leg  has amended.  The
 amendment is very slow ; and, in  many cases, the affected limb con-
 tinues  weak  and of a morbid enlargement through life.
   The latest and best writers upon the  subject, Mr.  White,  Mr.
. Trye, Dr. Ferriar, and  Dr. Hull,  concur in  deriving the disease
 from some affection of the  lymphatics of the distended side, though
 the^ differ as to the nature of such  affection.  Mr. White supposes
 it  to be  an extravasation from the  lymphatic  vessels  ruptured  by
 the pressure of the child's head against the brim of  the pelvis dur-
 ing a severe  labour-pain, the  extravasated fluid not  being duly ab-
 sorbed.   Mr. Trye refers it to inflammation of the lymphatic glands: 
WE. XI.-SP. I.]       SANGUINEOUS FUNCTION.              319

Dr. Ferriar to inflammation of the side affected generally: and Dr.
Hull to lymphatic inflammation and an effusion of coagulable lymph,
instead of an  effusion of the proper fluid of the lymphatics,  by a
rupture of their coats.  The last, if not the real cause, is the most
plausible  thus far  offered.   The lymphatics are capable of being
strained  and  weakened  during the progress of labour, and the  in-
flammation may follow from undue distention in  consequence of such
injury : but were the lymphatics to be ruptured during  labour the
disease would probably show itself much  sooner than the second or
third week after delivery.   There is, however, another way of ac-
counting  for this  inflammatory affection  of the lymphatics of the
lower limb,  and which, upon  the  whole, I cannot but think  is its
real source.  It is that of supposing an habitual debility in the lym-
phatics affected, and inflammation produced in them, from what Mr.
Hunter calls, though with some looseness of expression, the stimu-
lus of relaxation: in other words, from the weakly lymphatics, now
destitute of the surrounding  pressure  and stimulus which they pos-
sessed during pregnancy, yielding too easily to the flow of the fluid
they have to convey, and on this  account  becoming  morbidly dis-
tended, and inflamed in consequence of such  distension.  And we
may hence see why sparganosis puerperarum occurs in no other limb
or part of the body than the lower extremities.
   It is not to be wondered at that the  effused fluid should exhibit a
thick, glutinous, and even  milky appearance:  for we have had fre-
quent occasions of noticing a somewhat similar secretion in the case
of inflamed membranes, and even in inflammation of the heart itself;
and, at  the time we are contemplating, there is a general tendency
in the constitution to produce  genuine  milk, and  often in great
abundance.   Nothing can be more unlike than this  complaint and
dropsy, or than the effused fluid and serum: and hence Dr. Cullen
seems not less improperly  to reckon sparganosis puerperarum, a
modification of anasarca (anasarca serosa,) than those who have re-
garded it as a variety of milk-affection.  Serous dropsy of the lower
extremities occurs unquestionably at times after labour, but its symp-
toms, and appearance are altogether different.
   There is  apparently as  little  reason for the hypothesis of Dr.
Denman, who, while regarding it as an inflammation of the lympha-
tics, refers the inflammation to an  absorption of some acrimonious .
matter secreted by the uterus: for  the disease  has occurred where
there has been no more morbid action of the uterus than of the
mammae; and all the secretions have proceeded  healthily and in
their proper  quantity.
   The cure is to be attempted  first by leeches applied down the
course of the limb, poppy-head fomentations, and alvine evacuants -.
and afterwards, as soon as  the inflammatory symptoms have a little
subsided, by local stimulants, so  as to excite the torpid  absorbents
to increased action: of which the most useful in the  author's hands
has been the  volatile liniment with laudanum.
  The laudanum, on a cursory view, may seem to add to the vascu- 
320
ILEMATICA.
[CL. III.-OR. II.
lar torpor: but it tends to take off  the pain and irritation  that still
remains, and thus enables the tranquillized vessels the  more easily
to recover their tone.   Yet whatever application of this kind is em-
ployed, it  should be  accompanied  with gentle friction, continued
for half an hour or more, as the limb is able to bear it: for the fric-
tion itself is of essential service, and tends, perhaps even more than
any other local stimulant, to restore the limb  to a healthy action.
  Mr. Trye advises, for the same purpose, the use of mecunal oint-
ment ;  and others, that of small doses of calomel.   But neither have
proved decidedly useful; while in  some instances of  great debility,
they have evidently produced mischief.  The chronic weakness is
to be  removed by a continuance of the friction,  bathing with sea-
water, or, which  is much better, bathing in the sea itself, an elastic
flannel bandage, horse exercise, pure air, and, if necessary, general
tonics and astringents.
                        SPECIES II.

                BUCNEMIA  TROPICA.

              ftumtfclLefl ot  1Q|ot  <&Umxtt8.

THE TUMID  LIMB  HARD, LIVID, AND ENORMOUSLY  MISSHAPEN :  SKIN  AT
  FIRST GLABROUS, AFTERWARDS  THICK, SCALY,  AND WARTED :  SUCCES-
  SIVELY BULGING AND INDENTED :  OCCURRING  CHIEFLY  IN  TROPICAL
  CLIMATES.

This species is intended to comprize that singular disease,  known
in the West Indies, and generally over Europe, by the name  of Bar-
badoes-leg,  from  its being  indigenous to the island  of Barbadoes.
Yet it is not in Barbadoes alone that it  makes its appearance : for
it is of high antiquity, as well as of very wide range  in hot,  and es-
pecially in  tropical climates; and constitutes the genuine da  -fil or
elephant leg of the Arabians, being so denominated  from its livid,
tumefied, scaly, mis-shapen appearance.   As the Arabic dal or daul-
fil is literally elephantiasis or  elephant-leg, and as the Greeks dis-
tinguished  another  and very different disease by the name  of ele-
phantiasis,  the Greek translators of the  Arabian  writers were very
generally betrayed, from the unity of the name,  into a confusion of
the two disorders, as we shall have occasion still further to observe
when treating of proper elephantiasis under the fourth order of the
present class: and the confusion has, in  a considerable degree, des-
cended to our own times, insomuch that  many writers of the  present
day continue to jumble the elephantiasis, or elephant-/eg, of the Ara-
bians, with  the elephantiasis, or  elephant-sfci/i, of the Greeks,  and
to describe them as a common  affection, though no two complaints 
OE. XI.-SP. It.]
SANGUINEOUS FUNCTION.
321
can be more unlike: the former being a mere local malady, produc-
ed accidentally, and confined  to the individual who labours  under
it; and the latter a constitutional disease, in every quarter heredita-
ry, and in most quarters contagious.
  The Arabians, however, had the disease called elephant-skin, the
elephantiasis of the Greeks,  by themselves called juzam as well as
the dal-fil or elephant-leg, the disease before us.   And, as  the ma-
lady called  leprosy, and by the Arabians  beras, was supposed by
many physicians, as well Arabian as Greek, to terminate frequently
in juzam, or proper elephantiasis,  the disease before  us has occa-
sionally also been confounded with leprosy as well as with elephant-
skin, and all the three affections  have been huddled  together by
many writers into  one common disease.  Even Dr. Schilling,  a late
practitioner of considerable merit at Surinam, has not  escaped this
last error; for he  describes the tumid-leg under the name  of lepro-
sy ; confuses its earliest symptoms and appearance with those  of the
leprosy of the Greeks, and especially with those of the  lepra or
lepriasis canescens, and then distinguishes elephantiasis, the disorder
he professes to  be the immediate  subject of his  pen, as a peculiar
branch of leprosy, merely varied by its commencing  in the feet, in-
stead of in any other part of the body: and, carrying on the confu-
sion, he  next interprets the tumid-leg, or disease before  us, as a
mere variety of elephantiasis.*
   A summary of Dr.  Schilling,s publication is  given in the  Edin-
burgh Medical Commentaries,  and even the learned editors  them-
selves seem to  have adopted his views:  for the following is  thoir
explanation of the  general subject before us : " In some instances of
this  disorder (leprosy,; the feet are the parts  chiefly affected, and
then the complaint has been  termed  elephantiasis,  not only from
the resemblance of the diseased feet to those of the  elephant, but
from the walk of such patients  resembling  exactly the step of that
animal.   In this species of the complaint the  skin and other soft
parts become wonderfully expanded, at the same time that the dif-
ferent small bones swell considerably.  The toes  become thick, and
at last melt down, and run together as if made of wax.  The sligh-
test affection of  the diseased  parts occasions a discharge of blood,
which,  however, is commonly  easily put a  stop to.   The  disorder
by degrees spreads from the toes over the whole foot, and thence
proceeds  to the femur, rendering  the different  articulations  in its
course stiff and immoveable:  at the same time that, in many instan-
ces, the  muscles and  tendons concrete so  firmly together that the
most  skilful anatomist can neither  separate nor distinguish  them
without great difficulty."!  Dr. Schilling adds, that notwithstanding
the frequency  of this disorder  in some of  the West  India  islands,
and in some parts of the continent of America, he is clearly of opin-
ion it is not a disease of those climates, but was introduced, and con-
* G. G. Schillingii de Lepra Commer.tntioties, Cvo. L"H. Or. 1776.
t  Edin. Med. Coram. Vol. v. p. 26 I.
VOL. ii.                  41 
322
HiEMATICA.
[CL. III.-OR. II.
tinues to be supported there by an importation of negro slaves from
the cojist or Africfl
  For a distinct and more correct account of  this species, we must
turn to the writings of Dr. Hillarv* and Dr. Hendy, who have judi-
ciously  separated  it from both the leprosy and the  elephantiasis of
the Greek  writers, and treated of  it as an individual malady: the
former under the name  of " Barbadoes leg," and the latter under.
that of the  " Glandular disease of  Barbadoes."   It is singular how-
ever that Dr. Hendy should have  adopted the erroneous idea that
the disease before us is not only endemial to  Barbadoes, but that it
is to be found no where  else ;  and that patients  who  migrate from
this island  for  a cure, are almost  sure to abtain one, unless  in  a
chronic or inveterate stage of the disease, to whatever quarter they
direct their course.  It has been known immemorially in India, and
is  by the oriental writers,  and even by Sir William Jones, justly
distinguished from the juzam, which he  tells us must  not be con-
founded with the dal  fil, or swelled legs  described by the Arabian
phvsicians, and very common in that country. It is also indigenous
to the  Polynesian isles, where it  takes the name  of yava-skin, as
being supposed to originate from  drinking  the heating beverage
called yava;  and, like the gout among ourselves, is  regarded in a
sort of honourable light.
  The tropical bucnemia, like the puerperal, is occasioned by an
effusion of coagulable lymph into the cellular membrane under the
skin of the part affected, in consequence of inflammation of the lym-
phatics  of the lower limb, and  especially of the inguinal glands; the
cause of which is perhaps different in different  cases, but which is
most commonly cold,  operating upon a set of vessels peculiarly ir-
ritable, and especially so when affected with inflammation in tropi-
cal climates.  The blood-vessels, and particularly those of the sur-
face, are here  also greatly, relaxed; and hence  the skin, instead of
maintaining the paleness of the first species, very soon becomes suf-
fused with a  deep red or purple hue ;  while the saburral fluid, that
exudes  from  the cutaneous exhalents, concretes,  as its finer parts fly
off, into rough  and sordid scales, and the skin itself becomes enor-
mously thickened and coriaceous.
   The  effusion is usually  preceded by a febrile  paroxysm induced
by the  glandular inflammation just noticed;  and which, from the
first, discovers  a  tendency to recur, though often at irregular peri-
ods, so  as to resemble an erratic intermittent.  Every  fresh attack
adds considerably to the effusion,  and consequently to  the  morbid
size of the limb, and exacerbates  every symptom: and hence the
greater severity of this species than of the  former,  and the  mon-
strous disfigurement of the leg and  foot by which it is distinguished.
In  many instances also the inflammation extends to the surrounding
as  well as  to the  descending parts; and hence the scrotum, like the
pubes in puerperal bucnemia, is often peculiarly  affected and dis-
* Works, Vol. i. p. J49. 4to edit. 1799. 
1
 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 such 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; which,  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 guickly as possible ;  and
 then to  direct  our  attention to  a prevention of the paroxysms to
 which 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 walking, 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
 wine every morning fasting, was erroneously supplied with half a
 pint of what afterwards appeared to be the juice of the roots of the
hemlock-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, with the intermission of one 
324
H.EIUATICA.
[ex. iii.-or. u.
day, he repeated  the dose with a slight diminution in the quantity
The effects were still  violent,  though somewhat less, alarming
and  he  persisted  in using half the quantity for •evel?1.we;f'   *
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 tria  of,
but apparently without any success.  Dr. Schilling informs us, that
in some a  locked jaw takes place about the seventh  day from  he
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 will
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.f
                    GENUS   XII.

                      ARTHROSIA.

                 ^rtttttlar Enflammattou.

INFLAMMATION MOSTLY CONFINED TO THE JOINTS ;  SEVERELY PAINFUL J
       OCCASIONALLY EXTENDING TO THE SURROUNDING MUSCLES.

Arthrosia is a term derived from xgipu,  " to articulate," whence
arthrosis,  arthritis, and  many  other medical  derivations.   The
usual  term for the present genus  of diseases,  among the Greek
physicians, was arthritis, 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,  was 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 which 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. r.xn.
t G. G. Schillingii de Lepra Commentationes, 8vo. Lugd. Batav. 1776.
t On tlie Glandular Disease of Barbadoes. 
GE. XII.]
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 :
 Berrius,  that they are convertible affections.  White-swelling, in
 oneof 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 cor-
 rectly so arranged by Dr. Parr.
   From the  close connection between gout and rheumatism, 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 doctrine was,
 that no two 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 we
 shall  have occasion, as we  proceed, to  notice the  co-existence of
 measles and small-pox ; and  1 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 for
 several days,  brought on by  a violent attack of lumbago, to  which
 she is still a victim,  and which renders her nights more especially
 sleepless and  highly painful.   I he constitutional disease  has in this
 case been  roused into action by the superadded irritation of the
 accidental disease ; and the two are  now 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 which  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 xVlr. Hunter had, at this time, drunk no wine  for four or five
 years, and allowed himself but little  sleep at night.
* Rat. Med. Part in. p. 122—137. v. p. 420. 
326                      flsmatica.           [cl.  hi.-or. »•

  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.          WHITE-SWELLING.
                        SPECIES I.

                ARTHROSIA  ACUTA.

                   &cute IMieumattem.

PAIN, INFLAMMATION, AND FULNESS, USUALLY ABOUT THE LARGER JOINTS
  AND SURROUNDING MUSCLES  ; OFTEN WANDERING ; URINE DEPOSITING  A
  LATERITIOUS SEDIMENT ; 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 :
a. Artuum.                      Pain felt chiefly in the joints and
  Articular  rheumatism.           muscles of the extremities.
C 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.
5 Thoracis.                    Pain felt chiefly in the muscles of
  Spurious pleurisy.               the diaphragm, often producing
                                 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
in 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,! the author cannot say  from his own prac-
tice ; but it is the remark of a physician who was not accustomed to
form a hasty  judgment.
  As a general rule  it may be asserted that rheumatic inflammation
does not tend to suppuration.  In a few rare  instances the contrary
has been known to take place ;J and in one or two cases I have my-
self been a witness 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 effused fluid 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  the  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 with
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. h. 19.
  t  Comment, de Morbis quibusdam. Art. 79.
  X  Morgagni, De Scd. et Caus. Morb. Ep. lvii. Art. 20. Med. Comment. Edinh
Vol. iv. p. 198. 
328
H;EMATICA.
[CL. III.-OR. II.
   The  fever is  generally accompanied with copious and clammy
sweats; but the skin still feels tense and harsh ; nor does the -weat
issue freely from the immediate seat of pam.   It seems to be an in-
effectual effort of the instinctive principle or  remedial power ot
nature to carry off the complaint: for it is by this evacuation alone
that we can at length succeed in effecting a cure.  But the  perspi-
ration will 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 anv 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  which nature herself seems to  point  out, and  en-
deavour by still farther relaxing the  extremities 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 with 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 with it 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  with 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 we learn from
Dr. Guthrie, is employed very generally both in gout and rheu- 
OE. XII.-SP. I.]
SANGUINEOUS FUNCTION.
329
 matism  with a  full assurance  of success, a  cure seldom  failing
 to be effected after three or four doses :* in  consequence of which
 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,t or even the antimonial powder with
 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  which 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 aGute rheumatism, '; 1 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."J  Yet in direct opposition
 to such feelings and  such assertion, confirmed  by numberless testi-
 monies of equal weight, we find the bark freely prescribed  from the
 onset of acute rheumatism, apparently with success, by  Dr. Morton.
 who seems first to have employed and recommended it  for  this pur-
 pose, down 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 lime 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 when 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.
     t Clinical Experiments, Histories of Dissections, 8vo. Edin. 1780
     X Mat. Mqd. Part  ii. Ch. n. p. 100.
     } On Fever, Dissert, in.
  VOL. n.                  4? 
330                    juematica.             [cl. iii.-or. n.

than a third of the entire number,  appear to have  been  cases of
acute rheumatism, or rheumatism in conjunction with 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 we to reconcile such conflicting results, and harmonize
the authorities now adverted to ?  I  have also  tried the bark in va-
rious instances from an early  period of the disease, and  when the
bowels were  free from confinement, but 1  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,
when necessary, as well  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 general-
ly, and is the most common form under which the disease  shows it-
self; yet the  few following 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 «r;e«es, 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.-3P. I.]
SANGUINEOUS FUNCTION.
331
way into the dramatic poetry of our own country, as in Shakspeare's
Timon,

                        The cold sciatica
            Cripple our senato s, 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 wastes
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 duplica-
tures or appendages, it  exhibits many of the symptoms of pleurisy
or  peripneumony.   But here, also, as in every other case of rheu-
matism, we have much greater tenderness upon pressure than in
phlogotic inflammation, while the pyrectic symptoms are considera-
bly less, and often highly disproportionate to the pain that is endured,
 so that the degree  of pain and of fever becomes no measure  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 some-
times enormously flatulent  and expanded, with a sense of  heat like
that of  a burning coal.  If the back or loins be pressed hard to ob-
tain 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 car-
 ried 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 sutfers 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 copious  bleeding may be  con-
traindicated, leeches or cupping have often afforded considerable

           * CartheuserDiss. de Lunibagine rheumatica. Fr. 1755.
             Scueid, Diss, de Lumbag. rheumat. Arg. 1704. 
332
II/EMATieA.
[CL. 11I.-0R. U.
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 without exciting moisture ; and hence it is  less useful
than camphor dissolved in oil,  or  oil united with  ammonia.  In all
these applications,  however,  the Iriction with 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 exites 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 wider 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 tatar emetic ointment has been
also frequently  made use of, and sometimes  with success:  it gives a
parmanent  irritation, but the exulcerations it  produces  frequently
prove foul and troublesome.  Dr. Perceval of Dubhn, in  a  manu-
script note  to the volume of Nosology, tells me that, in sciatica, he
has known the pain removed by a sweating course of James's pow-
der, after a considerable emaciation of the nates.
  Bark  and gentle  stimulants, as  guaiacum, bardana,  and seneka,
may in every  instance be  used with advantage, with a liberal regi-
men and chalybeate waters.
                        SPECIES II.

              ARTHROSIA  CHRONICA.

                   Ciinmfc 2tfmimattsm-

FAIN, WEAKNESS, AND RIGIDITY OF THE I ARGER JOINTS AND SURROUNDING
  MUMBLES ; INCREASED BY MOTION ; RELIEVED BY WARMTH;  LIMBS SPON-
  TANEOUSLY,  OR EASILY GROWING COLD ;  FEVER AND SWELl ING 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  arrange- 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.]        SANGUINEOUS FUNCTION.             333

Arthrodynia, for the express purpose, as he tells us, of having a dis-
tinct name  at hand for any one who may choose  to regard it  as a
separate  genus ;  and whoever is so deposed  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  species 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 work, '• 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 no doubt, indeed, that it is so; but as,  in many in-
stances, itis a distinct disease, characterized 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 heat is very  considerable, and  the pulse  usually upr
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 eightly 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 warmth.
   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, when 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
FLEMAT1CA-
[CL. ITI.-OR. n.
from the leaves of the melaleuca Leucodendron, are all employed in
their turn ; sometimes alone, where they combine a sedative with 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  besfand soonest removed  by warm sudonfics,  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;
which 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 continent for chronic than for acute rheumatism, and is certain iy
more entitled to a trial.   In our own country, however, 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, which is far preferable, the vapour-bath, brine, warm-bathing:
and have  afterwards kept the joint well clothed with flannel;  and
sent through the organ small shocks 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 use of the oleum jecoris aselli, common train oil, or that
obtained from the liver  of the cod-fish, not  long  ago so  extensively
tried, 1  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 power, 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."  Dr. 
OE. XIL—SP. II.]     SANGUINEOUS  FUNCTION.
335
Bardsley's dose was 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  1 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  III.

               ARTHROSIA PODAGRA.

                           Clout.

PAIN, INFLAMMATION, AND FULNESS, CHIEFLY ABOUT THE SMALLER JOINTS :
  RETURNING AFTER INTERVALS;  OFTEN PRECEDED BY, OR ALTERNATING
  WITH, UNUSUAL AFFECTIONS  OF THE STOMACH, OR  OTHER INTERNAL
  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  was 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 gutla were used  in medi-
cine synonymously, both importing defluxion, the old opinion is still
verbally preserved, and has descended to  us in the names of rheu-
matism and  gout, though  the old pathology has been abandoned.
"• \\ e have still," says Dr. Parr, " the  treatise of Carpinati publish-
ed at Padua  in 1609, De Gutta seu Junctuarum dolore;"  but  the
term may be traced to Valescus de Tarenta, who wrote  his Com-
* Medical Report*. 
336
H&MAT1CA.
[CL. IH.-Oft. H.
mentary early in the fifteenth century; and Schneider  in his Liber
Catarrhorum Specialissimus, published at Wittenberg in 1664, usu-
ally denominated the sixth volume, and peculiarly scarce, describes
the gout as a catarrh."*
  The resemblance between 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, while the second is rarely or never so.  We have  also ob-
served already that gout  is far  more  connected with  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 tar more complicated complaint than rheu-
matism : and hence there is no  disease to which the human frame
is subject that has led 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, ihere is no disease concerning the nature
and treatment of which physicians are so little agreed : so that to
this moment it constitutes perhaps the widest  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 1 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? with 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 which 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 way 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 diathe-
sis is, in some instances, original, and in others  hereditary or deriv-
ed.   There are  many persons in whom this complaint makes its ap-
pearance, who 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.J      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
sytem, 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  many respects  it  makes a near approach, may remain
quiescent and not discover itself  for years, till it meets with some
occasional cause of excitement, when it  shows itself by  a sudden
and painful disturbance of  some  part of the  system,  but  a distur-
bance  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 :—

x  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.
C  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-
   Relrograde ;  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 boon observed,  is plethora with
entonic condition of the vessels.   And hence in its origin, as well as
  vol. ii.                    4 3 
338
HjEMATICA.
" [CL. III.-OR.  II.
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  |s more disposed  to  show  itself, where it has
been transmitted hereditarilv  n men of robust and large bodies, of
large heads, of full  and corpulent, and especially gluttonous  habits,
or whose «kin 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  what  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.
   ;uch is a brief history of the origin, hereditary  transmission, and
effects  vf 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 per-
haps through the whole term  of a man's  life.   And hence it is that
we often see  an individual, whose ancestors have been notorious for
this complaint, pass the whole of his days without betraying any
marks of it, while it appears in one or more of his  children, perhaps
in their very 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 m the system, or of throwing 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 pa-
roxysms in different individuals are often produced by intoxication,
or excess of eating; violent emotions of  the  mind, particularly the
depressing  passions, as  grief  and terror;  sudden exposure to cold
when 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;
cold, 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 catamenia, 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- 
€ME. XII.-SP. III.]     SANGUINEOUS  FUNCTION.             339

sional causes just adverted to, mav be doubted.  Such  an opinion,
however, has prevailed among the vulgar as  well  as among  many
of th- 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
©fophthalmy;  whence Lucretius,

       Atthide tentantur gressus, oculeique in Achsis 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 Germio provinces, are exempt from the attack
of gout, while  in our own  country it exercises an almost irresi-t-bie
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 entangle'! 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,
 however, 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
alkali.
   This morbid material, in whatever it consists, was supposed to  be
separated from the system and thrown off J 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 inform^ us that he has known dogs  affected with the
 same disease by licking the ulcers that have followed  upon a tit 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 he 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 Rer. Nat. vi. 1117.
  t Le Conte, Nouvnlles Memoires sur l'etat present de la Chine.  Paris 1696.
  X Sciiarler Vers. ii. p. 176, who denies it: and Degner De  Dysenteria, who
maintains it. 
340
HjEMATICA.
[CL. III.-OR. 11.
of tone in the extremities, often communicated to the whole system,
but especially to the stomach, succeeded by a powerful 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.
   1 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 we 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
lower  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  over
the eye-lids or in some other organ.J
   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 in 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 Piiys. Part i. B.  n. Ch. xiv. dxxxui.
  t BuUer, Nadere out dckkinge der menschelyke Waters. Harlem. 1697.
  i Eph. Nat. Cur. Dec. i. Ann. in. Obs. 252. 
GE. XII.—SP. III.]    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; when 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 : whence, 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, weight, 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 weakness : 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                  HyEMATICA.               [CL* IH.-OR. »•

   It is a remarkable fact, hitherto indeed little dwelt upon and alto-
 together 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 loaJed
 with nodules of lime-stone ;  and where a powerful 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 weakness of chronic gout; every affected joint becomes
 loaded with its secretion, which collects and hardens into nodules
 in its  cavities, or  in the adjoining cellular membrane, or  bursa?
 mucosae,  and rentiers  motion  uneasy  or  destroys it  altogether.
 The lime-stone, moreover,  as  .t 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 discharge.
 For  the  same reason nephritic calculi are often  a sequel of gout
 when it  has assumed a  chrome 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 secono
 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 or
 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
 derangement is renewed ; sometimes slowly subsiding after a con-
 tinuance  of several weeks;  and sometimes wearing out the entire
 frame, and terminating in abdominal or cellular dropsy.
  It sometimes  happens, however,  that while the  general constitu-
 tion ot 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* 
8-E. XII.-SP. III.]     SANGUINEOUS FUNCTION.
343
mation in a.gouty  habit, the inflammation seizes  ordinarily upon
the weakest part of the body, it makes its assault  u,>on s.jch or»an
rather than  upon the hands or the feet;  or, if it commence  in ^he
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 paroxvsm 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, stranguary, 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
regular fit of the disease.
  It was formerly the belief, as we have already seen, that a gouty
paroxysm was an effect 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  was
hence, also, conceived, in addition, to adopt the language of Syden-
ham, that the more vehement the fit, the sooner  it will be over,
and the longer and more  perfect the intermission.  And in  thi6
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 oi 
344
HSMATICA.
[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,  however, 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 impor*
 tant organ: while opium, though it affords relief in present parox-
 ysms,  occasions them to  return  with 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 opin-
 ion of  Sydenham,  Cullen, and  every other  physician, hastens on
 another, renders its intervals shorter, and its duration longer;  and
 progressively saps all the energies both of mind and body, and ren-
 ders life  itself a burden; it is of  serious importance to inquire
 whether this fear of a repulsion, however well founded in some in-
 stances, 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, which is obtained  in other inflammations, ac-
companied 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 evinco,
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 where 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 Linos of the Practice of Physic, Aph. dlxix. 
'.;!■:. 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
thoroughly sbund constitution such migrations are not common.
   In unhealthy habits, however, the extremities are not the weak-
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 pro-
 portion to its debility in particular parts.
   These are rules which we cannot too 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
 without 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 down, there seems no reason why, in*
 stead of " committing the  person to patience  and  flannel alone,"
 we should not pursue the evacuating and refrigerent 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 without hesitation.  Thus, in  measles, cathartics  and  vene-
section are  not only in general use, but often indispensable; in the
height  of malignant scarlet-fever, we sponge  or  wash the entire
   VOL. II.                  41 
34b'
ILLMATIGA.
[CL. HI.-OR. If-
 surface of the body with  cold  water; and in small-pox,  not onl;
 purge freely, but expose the patient to the coldest atmosphere of
 the winter-season.                                     .....     c
   In  weakly habits, or  idiosyncrasies, or incidental debilities ot
 particular organs, we 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 we 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
 which the inflammation is to be transferred: but the parts of weak-
 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
 would  be thrown 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, without 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 which 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 was  the object of  his education to bestow upon him :  and 
«3E. XII.-SP. III.]
SANGUINEOUS FUNCTION.
347
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 down:  and hence it is rather to be  ascribed to  a
want 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 was 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 water, 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 two
 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 
348
HEMATIC A.          [CL- HI.-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 frequent!;/ 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 sytem of the pecu-
liar aura just adverted to, which may perhaps  be  called  the  aura
podagrica,  but which constituted no unpleasant sensation.
  The practice  before us, however, is by no means of modern 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 view 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:
while, with 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  Lusitanust m 1641 to Kolhaas,J 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 .TT
  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  1 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 known disability in any other important organ.
*• Aphor. Sect. v. p. 25.
t De Medicorum Princip. Historia, Lih. in. Amsterd. 1641.
X Baldinger, Neuer, Mag. Band. v. p. 521. 1788.
§ Abhandlungen und Beobachtungen.  Berl. 1789,
[| Do usu nivis medico, 1661, 8vo.
m Obscrv. Physico-med. Hamb. 1691, 4to. 
GE. XII.-SP. III.]       SANGUINEOUS  FUNCTION.            349

  Yet even here  we 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  where  vene-
section would be of  doubtful expediency; a  liniment of oil  of al-
monds impregnated with opium, rubbed on the tumefaction with a pro-
tracted and very gentle friction, I have often found highly serviceable
in mitigating the  pain ; and epithems of tepid water, 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,
warm water, 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 would do.
  At the samp time, the body should be cooled with gentle aperients
or injections; and while drenching sweats are avoided, which  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 where  the  pain is  very acute ;  for,
while 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 tq
return with  additional fury.   Yet it  should never  be  forgotten,
that it is a law in the history of gout, and  one to which 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 while, 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 not reduce it too much.  His beverage
should be cool and unstimulant: Sydenham allows 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
HEMATIC A.
[( L. 1II.-OR. II.
ties,  in retrocedent gout, on  the  contrary, to render the vacillat-
ing attack on the extremities more permanent, and prevent it from
shifting to anv 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 off the 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 we 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 within 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  we 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 which 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
where the bowels are confined, to add to it some warm aperient, as
aloes or 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
without 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 a 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. X1I.-SP. Ill*]
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.!
   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 the warm bath.
   But our sheet-anchor is opium ; and it should be given  freely, and
in union with 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
of 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 when a strong ir-
ritation is to be overcome, very iarge 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 where the at-
tack has  actually  shifted from the  feet or  hands to  some  internal
organ.  But where it still  lingers in  the extremities, though with
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 bowels moderately open
with rhubarb, aloes, or the compound colocynth pill.
   In gout,  however, the intervals of the  mscvse arc of as much
importance  to be  attended to as its paroxyms : and here, also, the
mode of management under the first  form should  differ essentially
* Physical and Literary Essays, Vol. n. Art. xii.
t Mat. Med. Part n. Ch. vm.
X Mat. Med. Fart 11. Ch. vi. 
352                   H/EMATICA.              [«*•• HI.-OR. tl>

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 way 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,  wines, and formented 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 sudden and violent transitions.  The bowels should be kept in
regular order, and the  hour of rest be early.
   A clue and  unswerving  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 known 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  with astringents and
bitters with great  and decisive benefit.   Upon this subject, however,
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 formed of 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
Car.lius Aurelianus in the second century to  that of Sydenham in the
seventeenth.   The famous powder purchased  by the second Duke
of Portland,  who distributed its receipt for general use  from  the
\"ot. I. Class I.  Orri. i.  C'j:i. v. t>nee. 7. n. 100. 
»E. XII.-SP. III.]
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 Gre k
 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-
 tiim, germander, ground-pine, and the tops and leaves of the leaser
 centaury.   The dose is a drachm taken  fasting every  morning for
 three months;  after which it is  to be reduced to three  quarter- 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 r#orning only, through the next twelve months;
 by which time  it is presumed that a core will be accomplished.
   The real  effect of this  and similar medicines is  very doubtful,
 and  the doubt arises from  the gradual mischief which 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 own 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 gradual-
 ly 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, where 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 w< • is 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 power with a perpetual tendency to torpitude in  every  part
 of the system.  !n 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 employpd, we
  vol.  nr.                       45 
354                     HyEMATICA.            [«- HT-OR. II.
have reason to expect indigestion, low spirits, dropsv, 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 ton;cs,  appear to produce in dif-
ferent  cases of gout, and tojustifv the caution with which they were
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 will 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 where 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 with 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 view of this subject.
He suppeses 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 warding off fits of this disease ; but
that, from  this deleterious property, when long persevered in, they
weaken the stomach and other organs  of digestion, to which at first
they gave  tone ;  and thus  ultimately  induce  the diseases we  have
just noticed, and which 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
u a fit of a regular or very painful  inflammatory  gout,  once at least
and frequently twice in the course of  a year; but who, after they
had taken  the Portland powder for some time, were 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 known, was the health of these
persons ioierably entire.  Soon  after  finishing  the course of their
medicine  they became valetudinary in different shapes,  and  par-
ticularly were much affected with  dyspeptic, and what are called
nervous complaints,  with lowness 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
 with  anasarca, in less than two or at most three years, proved fatal.
 These accidents, happening to persons of some rank, became very 
GE. X1I.-SP. III.]        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 which are here described.
And as Dr. Cullen gives us no account of any mischief that  has  fol-
lowed 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 produ-
ced 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 1 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 we  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 with 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 with 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 ft£x*
* Mat. Med. Part. n. Ch. n. 
356                    HtfMATICA.            [CL. IH.-OR. H-

'EAAEBOPOY of the Greeks was a different plant from either the
wh.i* or black hellebore of modern dispensatories
  The favourite specifics of the present day are M   Hussonj  hau
medicinale, and the vinum colchici,  or wine  of meadow ^flron, in-
troduced in the current Pharmacopoeia of the London College, chiefly
upon  the authority  and recommendation of  Sir Ev^ard Home
The exact components of the former are kept a  secret; though, it.
basis is  well known to be either the one or the other of the above
plants, most probably the meadow-saffron.  The  effects of the F,au
medicinale and of the colchicum-wine do not essentially differ; tor
after taking about sixty  drops of either the  pulse becomes slower,
and at  length sinks, in  about  twelve hours, from  ten to twenty
strokes  in a minute below its natural number, at which time the in-
flammation subsides.  The  action of both medicines is accompanied
with great languor and a deadly nausea or sickness, which termi-
nates in vomiting, or a discharge from the bowels, or both.  It 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 effei ts
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 jugular
vein.  From thirty drops he recovered in about seven hours;  from
sixty drops in eleven ; but  a hundred and sixty drops,  thrown into
the jugular vein, killed him, after having suffered  great agony,  in
five hours.  On opening him,  the stomach, smaller intestines, and
colon were 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 Flarnmula, 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  practitioners so attached  to the
 Cuilenian 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. xn. xm. 
GE. XII.-SP. HI.]
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, whether 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 1
do not  think that either the  F.au medicinale or  the colchicum-wine
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 he tried except in the first variety cf 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 restram the violence of the paroxjsm, 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,
(re in a state of chronic debility, and  the inflammatory fit, when 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 herehy 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  cf inflammation.   The opera-
 tor is  directed to seize the aching  toot 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  yielded  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 1 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 1  have ever
attended a patient who would have consented to the advice if I had 
358                     HvEMATICA.            |>L. W.-OK. II.

given it.  The direct object is to overcome the inflammatory action
by constringmg the vessels;  but this effect is more readily obtain  d,
and in a far easier way, and  with quite as little risk, by cold water.
If in the course of the compression the inflammatory action do not
soon yield, it  should certamly 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 inflammation* of other kinds.   A young
woman with 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 was 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  own person, which  was that  of eating  strawberries.
The story is  pleasantly told  by M. Hedin in the Amcenitates  Aca-
demical.  And having in this agreeable manner driven away the
paroxysm by  which he was  then  assaulted, he persevered  in the
same mode of relief through five other fits which attacked him an-
nually, every attack however being slighter  than  the preceding;
till, by persisting in the same fruit, the disease, it is said,  did nc£
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 dependance  upon them.
                        SPECIES  IV.

           ARTHROSIA  HYDARTHRUS.

                     Wnitr^Storllinfl.

TENSE,  PERMANENT, COLOURLESS SWELLING, CHIEFLY OF  THE  LARGER
  joints:  inflammation  slow, and  deep-seated: pain fixt  and se-
  vere: IMPERFECTLY SUPPURATIVE : FEVER A HECTIC

This inflammation, like that of rheumatism, attacks the larger rather
than the smaller articulations.  Yet, as the joints are  uniformly the
seat of its assault, and it runs through its course without the produc- 
GE. XIT.-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  we  find this
predisposition showing itself also, as we  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 two 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:

       a Entonicus.                Entonic White-Swelling.
       C  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.*  l,t 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.
   These causes I  have stated to be chiefly strains, and other exter-
ternal  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  ot the  joints : though, according to Mr. Brodie, it sometimes
commences  in the circumambient  cellular substance.!  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 which  was dis-
charged in a case related by Dr   Simson, by making an  opening
through the integuments and synovial membrane.   I he occasional
cause was 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 with cartilage.
* Treatise on Ulcers with  a Dissertation on White-swellings, &c. 8vo.
t Pathological and Surgical Observations on Diseases of the Joints, 8vo. 1818. 
360
HJEMATICA.
[cl. III.-OR. n.
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  whose nature
he was ignorant, immediately under the  pate la,  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 twelvemonth.   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 affects 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, however, 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 few 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 with 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 ?eparate  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. XI1.-SP. IV.]
SANGUINEOUS FUNCTION.
361
will commonly  remain long afterwards; but which in most cases
will gradually yield to friction with the hand  alone,  or, which is
better, illined with 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  amputa-
tion.
   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 cir-
cumscribed, and appears  to shoot  almost from a point, and the swel-
ling 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
mmute 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."!
   The occasional causes  are sometimes those of the preceding va-
riety; but the disease more generally commences without our being
                  * Patholog. and Sug. Observ.
                  t On Blood, &c. p. 391.
VOL. 0.                     46 
362
H/EMATICA.
[CL. III.-OR.  U,
able to trace any occasional cause whatever :  and is far more dispo-
sed than the preceding to terminate in a fatal hectic.
  The practice is most disheartening and the  prognostic  most mel-
ancholy   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 other joint.   The pain may be soothed with
opium; and local stimulants have been found useful in a early stage
of the disease, or where 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 with 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 descri-
bed, the tumour, when  in  an incipient state,  seems to have been
quite as favourably acted upon by the attack of some unforeseen ex-
anthem, as  small-pox or miliary  eruption, as  by any  topical  plan
whatever.J

  * Heister, Wahrnehmungen B. I.   Wendt, Nachricht von dem Institutum clini-
cum.  De Meza, Anhang zer Strack Abh. von der Petetschenkrankeit.  Plater,
Observ. L. ill. p. 704.  Bromfield's Observations.  Kirkland on the present state
of Surgery. Percival, Med. Corn. Edin. vii. 67.
  t Proett, Versuche einer Cbirurg.  Gesillschaft  in Kopenhagen.  Baylie, Pract.
Essays.  Michaelis, in Richter, Chir. Bibl. B. v. p. 113.   Stoerck, von der Schwar-
zen Kuchenschelle, p. 82.
  $ Med. Trans. Vol. I. p. 104. 
       CLASS  III.

HUMATICA.
                        ORDER III.


                EXANTHEMATICA.


                     Krujjtfte jFebcrs.

    cutaneous eruptions essentially accompanied with fever.

The term Exanthemata among the Greeks, from t%xv6ta, " 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,
Sagar, 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 specifica 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
febrile.
  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
in which fever exists as an  essential symptom;  whether accompa-
nied with or  destitute  of contagion; which last is a doubtful an<j
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 diffe
rent kinds, and that  are scattered over the entire classification,  as 
364                     HiEMATICA.           [<L- I""0*'  1H

dysentery and influenza, in which there is fever without cutaneous
eruption; itch, and many varieties of tetter, in which there is  cu-
taneous eruption 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. EMPHLYSIS.             ICHOROUS  EXANTHEM.
     3. EMPYESIS.              PUSTULOUS EXANTHEM.
     4. ANTHRACIA.            CARBUNCULAR EXANTHEM.

  Each of these, with the exception of the third, comprises seve-
ral species: and all concur in evincing the existence of morbid  and
specific poisons in the blood, acting  tj-e 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 which 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
power 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 en 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 n. Ord. n.  On Inflammation, p. 161.
t On Blood, Inflammation, &c. pp. 236. 450.467. 
CL. III.-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 w 11 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 muftiplying 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 water 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                      HjEMATICA.


                       GENUS  I.

                      ENANTHESIS.

                     J&asli Epantiiem.

ERUPTION OF RED, LEVEL, OR NEARLY  LEVEL PATCHES ; VARIOUSLY FI-
  GURED ; IRREGULARLY  DIFFUSED ; OFTEN CONFLUENT ;  TERMINATING IN
  CUTICULAR EXFOLIATIONS.

The term enanthesis is derived from the Greek v$ " in, intra," and
xtdw " 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
scarlet fever, compounded of papulae, small  acuminating elevations
of the cuticle,  not containing a fluid, as in the case of measles ; or
existing 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.
    2- ---------- URTICARIA.            NETTLE-RASH.
                         SPECIES  I.

              ENANTHESIS ROSALIA.

                      ,Scarlet=iPctar.

RASH,  A SCARLET  FLUSH,  APPEARING  ABOUT  THE SECOND DAY ON THE
  FACE, NECK OR FAUCES; SPREADING  PROGRESSIVELY OYER  THE BODY '
  AND  TERMINATING ABOUT THE 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.
[CL. III.-OR. III. 
GE. I.-SP. I.]
SANGUINEOUS FUNCTION.
367
  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 bad 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 miliaria
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. Willant 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 ta
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 comparatively
modern  origin.   Some writers fancy that they can distinguish a few
traces of one or two of these in the works  of Paulus  iEgina,  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, hosalia, and even  morbilli
evidently point to the school  of Cordova, and lead us to the Arabian

                * Med. Contin. Tom. i. Cap. vn.
                t Recueil Periodiquc. n. 337.
                X Cutaneou? Diseases, p. 253. 
368
H^MATICA.
[CL. III.—OR. III.
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 was  with  measles; whence it is difficult, in one or two
instances, to determine what is the precise species of disease refer-
red to by Avicenna, Haly Abbas and Rhazes :  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 efflorescence,  are, among the earliest
writers  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 rouge-
ole, which among  the French writers 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 senapion.*  And, in  this man-
ner, both diseases continued in every country till  within 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 writings 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 presently,  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.
  Simple scarlet-fever.


£ Paristhmitica.
  Scarlet-fever with sore throat.
Fever moderate, and terminating
  with  the  rash ;  little prostra-
  tion of strength : slightly con
  tagious.
Fever severe ; throat ulcerated;
  rash  later in  its appearance,
  and   less  extensive ;   often
  changing to a livid hue:  high-
  ly contagious.
* 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 dav 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, with 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 widen, and the florid hue fades. ^)n 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 with  scarlet  points  from  an elongation  of the
 turgid papillas; 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
 ^fcietimes 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,  who has copied Sauvages's definition, re-
 present the efflorescence  as not tal.'uj 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 accuratefy  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,4makes its appearance."!  Generally speaking, the

      * Med. Trans. Vol. m.  p. 397.
      t M. A. Plenciz, Med. Vindoin. Tractatis de Scarlatina.  1776.
   vol. ii.                   47 
370                     HtEMatica,           [cl. iii.-or. hi.
more violent  the  attack  the  sooner the efflorescence is thrown
forth :  and hence,  during a severe and extensive range in Newcas-
tle-upon-Tyne in 1778, Dr. Clarke  tells  us  that,  where  it  began
with great vehemence, the eruption  was often observed on the hrst
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 with
measles, to which, indeed, it bears, 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, which do not  belong to scarlet-fever; and is
without that restlessness, anxiety, and depression of spirits by
which 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, which(jp  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 themj||
 the sixth or seventh day from the commencement  of the  erupti™
 chiefly in the hands and feet: in other words, at the time when the
 turgid cuticular vessels had contracted and the efflorescence was oa
 the decline.   On examination,  he further tells us that they  appear-
 ed  to be nothing more than  cuticular elevations filled with 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.
            t Class in. Old. Exanth. Gen. vm.
            X Tractat. de Scarlatina.
            6 Med. Trans. Vol. v. Art. XI. 
GE. l.-SP. I.]         SANGUINEOUS FUNCTION.              371

alluded to, showed 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 of interval between the  time of  exposure to
the attack in those who sickened nearest to each other  in the order
of its descent, and any sensible effect on the system ; which instead
of being, as in  ordinary cases, four, five, or  six days, was, upon an
average, not less than twenty-one days; varying in different indivi-
duals, from seventeen to twenty-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 new complaint
requiring a distinct designation.   Yet if we reflect  how  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,  we
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, where 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 general 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 velum 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.t   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 velum  pendulum  palati and lower part of
* Buchholz Tode Med. Chir. Bibl. Band. i. p. 86.
+ Dr. 'rims. Memoirs of the Med. Soc. of Lond, Vol. i. p. 394. 
372
HLEMATICA.
[OT,. III.-OR. 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 papilla* over  its  entire surface are 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 with 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 with whitish 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, however, 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. 
OE. I.-SP. I.]        SANGUINEOUS  FUNCTION.              373 .

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 writers 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 with 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 debili-
tating 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 two, he observes,  after Dr. Fothergill, that the angina
ganorcenosa (sore throat with scarlet-rash) usually commences in the
winter  or ihe spring, and chiefly attacks persons of delicate habits,
as women and children ; while the scarlatina anginosa (scarlet-rash
with 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 .'Vewcast|e-upon-Tyne in
1778, seems to have reversed  this rule  in its most essential point;
for Dr.  Clarke to whom 1  have ju^t 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, &c. 8vo. 1779. 
374
H^MATICA.
[cl. III.-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 ot the dis-
ease ; and contains one or two remarks which very agreeably dis-
play the observant tenour of the writer's mind.
  " Cynanche  tonsilaris and maligna, 1 consider  with you as a spe-
cies  of rosalia.   All have been  produced by the same specific con-
tagion,  which  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
were 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 upwards 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 paristhmi-
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  without 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, 1 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 we have abundant proof ol
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 particular 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 laws  of febrile miasm which, under different circumstances, ori-
ginates both within and without the living body, we had occasion to
observe that, when 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 receiv-
ed 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 degee,
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 e ddemic.
Or, in other words, we behold the predisposing state of  h: atmos-
phere observing the same restriction as  the disease itself when it
operates independently  of any such predisposition.  Adults, indeed, 
376                     hjematica.            [cl. iii.-or.  hi.

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
coll, and at others upon a surfeit of the 6tomach;  but as these are
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.
  AH exanthems and nearly all fevers produce  an influence on the
sysipm that renders it less susceptive of the same complaint for a
certain period of time afterwards: yet the period varies  from the
p' Tue, 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 whole 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, and 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
show itself till the twelfth or fourteenth day, and often considerably
later, when 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 winter 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 
OE. I.-SP. I.]
SANGUINEOUS FUNCTION.
377
 it is  occasionally to be  found after  the  mildest  form of the dis-
 ease ; 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, we may say with Dr. Sydenham, that the dis-
 ease hardly calls for medical assistance of any kind.   When the fe-
 ver is mild, it forms, as we  have already observed in respect to ex-
 anthems of all kinds, the  natural means of  cure by determining the
 specific poison to  the  surface.  An  emetic may assist this determi-
 nation, and has  hence been almost always found serviceable; and if
 the bowels be confined, an aperient may follow ; but violent purging
 will add to the irritation, and distract  the  remedial course that is
faking place.
   In the paristhmitic  variety, the determination, instead  of being
 to the skin generally, is pov, erfully deflected to the  throat and head,
 and the fever is alarming from its violence.  The  therapeutic in-
 tention is here to counteract this morbid dow 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; with the additional
 fact, that we have here to  deal  chiefly with 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 ha3 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 that
 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 177!!, 8vo.
vol. n.             '  48 
378
ILEMATICA.
[CL. IH.-OR.-IIf*
 any hypothetical good; and it will often be proper, as recommend-
 ed by" Dr. Withering, to repeat it occasionally, as the foul and in-
 fircted state of the fauces may require.
   We have just observed that this distinguished physician prohibi-
 ted purgatives as well as bleeding.  But in doing this he discover-
 e I 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 which 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, however,  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 powerfully
 recal 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,
 whether 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 dependance 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 re-
 freshment  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 were
 decomposed and a part of its  oxygene  were swallowed greedily by
 the thirsty absorbents of the skin, which 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 paristhimitis; or fumigated  with
 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 course  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.   1  have
never tried it, nor can I very clearly trace out the  path by which
any benefit may be hence expected.  Wine and nutritious food may

          * Tractat. de Scarlatina.
          + Rat. Med. Continuata. Tom. i. Part i. 8vo. Vienna. 
<*E. I.-SP. II.]        SANGUINEOUS  FUNCTION.              379
                                              /
be  allowed, but somewhat less freely  than in malignant quinsey.
The convalescent  state requires  great care; and a damp cold at-
mosphere should be especially avoided from the  tendency to dropT
sical swellings.
                        SPECIES II.

              ENANTHESIS  RUBEOLA.



RASH IN CRIMSON,  STIGMATISED  DOTS,  GROUPED IN IRREGULAR  CIRCLES
   OR  CRESCENTS ;  APPEARING ABOUT THE  FOURTH DAY, AND TERMINAT-
   ING ABOUT THE  SEVENTH J 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 :—

x  Vulgaris.                       Rash slightly prominent extend-
   Common Measles.                 ing over the mouth  and fau-
                                   ces ; harsh, dry cough, inflam-
                                   ed, watry eye.
ff  Incocta.                        flash running its regular course,
   Imperfect Measles.                with little fever or catarrhal
                                   affection; affording  no  cer-
                                   tain security  against the com-
                                   mon or regular disease.
y  Nigra.                         Rash about the seventh or eighth
   Black Measles.                    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 varie- 
 380                   JLEMATICA.              [CL. I1I.-0K. III.

 ty usually shows 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 i.i
 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 tumified,
 the  vessels of the conjunctiva turgid and  inflamed, the cheeks are
 wet with 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 drowsy; 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 atten-
 ded  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 two diseases may be distinguished, and the following may
 be added  to  the  number.  In scarlet-fever there is no cough, the
 eyes do not water,  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 cou°-h,
fever, and head-ache grow more violent; and the  difficulty of breath-
ing, weakness, of the eyes, and  inieed 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 peri-
od we have  already stated to be the fourth day, but it occasionally
appears on the third, when the patient commonly escapes  with 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, Waarneeiningen. 
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  which 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 state of the
lungs or some other phthisical diathesis.
   If, on inoculation for  small-pox, rubeolous contagion should have
been previously received into the svstem, the variolous action will
generally be, though not always, 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," savs 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 course of pregnancy, and recommences its
inroad on child-birth.
   Measles  in their  more  perfect form,  which is that we are now
contemplating, may be said, as a general rule, to occur but once in
the course of a man's life ; for though  a few  instances of a second
attack are to be found exceptio probat regulam ; they are so rare as
rather to maintain  than disturb  the law.t  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 with
danger.  It is  in fact a catarrhal  fever with a specific eruption.
The fever, as we have  observed already respecting exanthems in
general, is  necessary to  a certain extent for the purpose of throw-
ing the virus upon the surface; as  inflammation in  a certain extent
is necessary to produce healthy suppuration.  But a small degree
of pyrectic action is in both cases sufficient ; for if this be exceed-
ed, 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 whenever 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.
          t Roberdiere, Reclierches sur la Rougeole.  Paris  1776. 
382
HJEMATICA.
[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, however, 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, we 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 which 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-
ng on this species as given in the Nosology, " typhous infection was
introduced ; hence the variety x changed to 6."   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 analog}', 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 which exposure to  cold would, in the  opinion  of every  one, be
absurd and  mischievous; nor  can any thing be so likely  to produce
pneumonic inflammation, which, in truth, is most commonly the re-
sult  of carelessness upon this very point.  The room should be
large and airy,  free from currents of cold, but  not hot; the  drink
warm, the food light, diluent, and in a liquid form.   If the cough be
troublesome, if will be useful to  breathe the steam of warm-water,
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 diarr-
* Medical Observations, Vol, iv. Hoffman. Opp. Tom. n. p. 67. 
GE I.-SP. II.]         SANGUINEOUS  FUNCTION.             38^3

hoea proves the most favourable crisis, and should be very cautious-
ly 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 time, the rubeolous rash is sometimes found
to run through its regular course with little fever  or catarrhal  af-
fection, 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 when the genuine  measles are epide-
mic, 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 ; which is the best protection we 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 inter-
mixture 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 other 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 with ease to  an infusion
of bark with sulphuric  acid.
   Inoculation has been tried  for the measles by  employing the ac-
rid 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  where 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
* J\7ew York Medical Repository, Vol. v. Art. in. 
384                      ha:matica.           [cl. iii.-or. hi.

range excites so little alarm;  and which leaves no blemish, like the
small-pox, on the skin.
                        SPECIES III.

             ENANTHESIS  URTICARIA.

                        J£ettle=iUsU.

RASH  IN  FLORID,  ITCHING,  NETTLE-STING WHEALS ;  APPEARING  ABOUT
  THE SECOND  DAY ;  IRREGULARLY FADING AND REVIVING, OR WANDERING
  FROM PART TO PART : TEVER A MILD REMITTENT.

This, like the last species,  is rather a troublesome than a dangerous
complaint; though it is always attended with 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 wri-
ters.   The resemblance is  close ; but there are characters by which
the two diseases may be distinguished with tolerable ease.   In net-
lie-rash the efflorescence is in scattered wheals with few papulae;
in lichen, in scattered papulae with few wheals.  In the latter the
itching is more mordant and aculeate ~,  the eruption instead of ter-
minating 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, which*has  no wheals or elevated beds with a de-
fined  outline, and no sensation of stinging.
''  Medical Transactions. Vol. n. p. 17:!. 
 Ofc. I.-SP. HI.]         SANGUINEOUS  FUNCTION.            385

   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 account 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. Wi Han's
 treatise.
   A cooling regimen, and subacid diluents, with a free exposure  to
 pure air, generally succeed in effecting a  cure  of nettle-rash with-
 out any other medical  treatment.  A gentle laxative or two howev-
 er 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 which urticaria proved  fa-
 tal.*  This patient was a  man of about fifty years of age, who^ad
 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 conside-
rable, 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. -lUI.
vol.  n:
49 
38b"                     H^EMATICA.           [CL. IH.-OR. III.



                      GENUS  II.

                       EMPHLYSIS.

                   ichorous  SSrantfiem.

ERUPTION OF VESICULAR  PIMPLES FILLED  PROGRESSIVELY WITH AN  ACRID
  OR COLOURLESS, OR NEARLY COLOURLESS FLUID ; TERMINATING IN SCURF,
  OR LAMINATED SCABS-

The term emphlysis is derived from the Greek t/t or •», " in, intra ;"
and ^At;««, " a vesicular tumour or eruption."   E*<pAt/«* is usually
employed among Greek writers nearly in the same sense as $xva.
In the  present system  it will be found  employed somewhat more
strictly, and in opposition to ift^Xw;  so  that while emphlysis, from
the latter, imports an eruption of vesicles, whether large or small,
produced  by  or  accompanied with  internal  and febrile affection
essentially connected with  it; ecphlysis, from the former,  imports
an eruption of vesicles simply cutaneous or  superficial; or, it^ in a
few varieties, combined with internal affection, not necessarily or
essentially associated.  Of the last, therefore, we shall have to treat
in the third order of our sixth class intitled ecchitica.
  The genus emphlysis includes the following species  :

1. EMPHLYSIS MILIARIA.             MILIARY FEVER.
2. --------- ArHTHA.             THRUSH.
3.---------VACCINIA.            COW-POX.
4. --------- VARICELLA.            WATER-POX.
5.---------PEMPHIGUS.            VESICULAR OR BLADDERY FEVER
6.---------ERYSIPELAS.           ST. ANTHONY'S FIRE.
                        SPECIES  I.

               EMPHLYSIS  MILIARIA.

                      JHtlfarj)  JFcter.

VESICLES SCATTERED  OVER THE  BODY,  OF THE SIZE  OF MILLET-SEEDS ;
  TRANSPARENT-RED,  AFTERWARDS MILKY :  PRECEDED  BY A  PRICKING
  SENSATION ;  SIGHING,  ANXIETY, AND SOUR SWEAT.

The disease takes its name from milia, " millet-grains," in  conse-
quence of the resemblance  of  its vesicles to the seeds of this plant
in size, and, when matured, in colour.   There is a doubt when it first 
 UE. II.-SP. I.]         SANGUINEOUS FUNCTION.             387

 made its appearance,  and another doubt among some pathologists
 whether it be ever any thing more than a symptom of some  other
 complaint.
  It has been treated of for  at least a century and a half, and that,
 too, as an idiopathic malady.  It is said to have appeared first of all
 in  Saxony;  and the  oldest writers assign  two  varieties  to this
 disease distinguished in Germany  by the names  of Rothen Friesel
 and Weisse Friesel,  or  red and white miliaria,* but perhaps unne-
 cessarily, as both varieties seem in most  if not in all instances to be
 only different stages of the same affection.  The vesicles are at first
 red from the colour of their under surface, or inflamed base, being
 transmitted through the  transparent pellicle ; they are  afterwards
 opake and milky from absorption of the  more attenuate  part of the
 fluid, or some other change.  In a few cases, however, the  red hue
 seems to have  continued throughout; and in others the  white hue
 to  have appeared from the commencement:  a variation  in  the
 nature of the secretion and in the mode  of its absorption producing
 this difference  of effect.
  From the redness of the vesicles on their first eruption,  this disease
 has also been denominated by many writers on the continent pur-
 pura ; and has hence been  confounded with the petecchial or flea-
 bite-like spots  that appear in scurvy and  putrescent fevers:  and  the
 rather as miliaria is also a disease of debility.   Ploncquet seems to
 have intermixed all these as well as pemphigus, and described them
 under the common name of miliaria.t   In like  manner Gerike's
 dissertation on  this disease is intitled De Morbo Miliari, alias Pur-
 purd dicto ;\  and Juck's De Febre Miliari, vulgo  Purpura rubra et
 alba, seu chronica.^
  From  the  minuteness of its vesicles, whose elevation can often
 only be ascertained by the finger, this species treads close upon the
 general complexion of the genus enanthesis, or rash-exanthem, and
 during its red appearance is often called  a rash ; and hence  another
 cause of confusion and intricacy.   By Linneus and Parr it is on this
 account defined nearly in the same terms as rubeola, so far as relates
 to the  eruption; and at Leipsic in 1650,  where it is said  to have
 been  contagious or  epidemic, was unquestionably mistaken  for
 rosalia or scarlet-fever.   As a symptom  it sometimes  accompanies
inflammatory fevers, but more generally  those of atony.  It is cer-
tainly  at  times attended with flea-bite  spots,  or petecchise, and
 Huxham speaks of it as sometimes giving rise to them :|| an obser-
 vation confirmed by a like statement of Boncerf :1F and hence  another
 reason why  it has occasionally  been treated of under the term
 purpura.
 * Sindner, Betrachtungen des Rothen und Weissen Friesel--,  Schvveiduiz, 17X"
 t Initia Biblioth. v. p. 564, 565.
 X Hal. 1733.
 i Erford. 1716.
 || Vol. I. passim.
If llantesierk, Rccucil, II. p. 21". 
388
HJEMATICA.           [CL. III.-OR. III.
   The eruption makes its appearance at an uncertain period after
the commencement of the introductory fever; usually, however, on
the third or fourth day.  It  seldom shows itself upon the  face;
but is first visible upon  the  neck and  breast, and thence  spreads
progressively over the entire  body.   The febrile  attack is usually
somewhat severe  in  all its stages,  the pricking  sensation  occurs
during the hot fit, and is  like that of pin-points struck into the skin ;
the sweat is copious, but proves by its sour and olid smell that it is
a morbid secretion, and  hence affords no relief.   The disease runs
on  with  variable  remissions  or exacerbations  for seven  or even
fourteen  days,  and has sometimes extended to twenty-one  days,
commonly  terminating in  a critical and  natural sweat;  the red
transparent  vesicles,  as already  observed, gradually  assuming a
whiter hue,  and losing their transparency; and about the  fifth day
drying in minute crusts  or scales;  which, in some  instances are
succeeded, as in thta case of aphthae,  by a new crop of vesicles that
pass through a  like  course.   Notwithstanding  the  anxiety and
depression of animal  spirits  which  so  peculiarly mark this  exan-
them, it commonly maintains through  its  entire  range  a mild
character undisturbed  by any alarming symptoms.  In some instances,
however, either from the constitution or peculiar circumstances of
the patient, or the peculiar temperament of the  atmosphere, it puts
on a malignant character and proves  fatal in a few days.
  We have no clear proof  of  its being contagious ; and Stoll,* and
most  pathologists  with  him,  deny  that it is  so at all.   In the
present day,  indeed, it is  found more frequently as a secondary or
symptomatic, than as an original affection.   Cullen denies  that it is
ever  otherwise than  symptomatic.   But this is  to  speak  in too
proscriptive a tone : for  I have  lately had a clear and well marked
example  of its idiopathic appearance in a young gentleman  of a
bilious habit, thirteen years  of age, in which the vesicles were
very numerous,  but distinct.   They  passed  through the two stage.«
of a  red and miiky hue,  and terminated  on the seventh day in
branny scales,  unconnected with any other ascertainable  disease:
and M. Planchon has given abundant  instances of the same kind.t
  Dr.  Cullen,  indeed, conceives  it  to be  nothing  more  than an
eruption  occasioned by a stage of sweating  protracted till it has
produced  debility, in  any fever whatever.   But  in  this  case we
should expect it most frequently in the clammy saburral sweats  of
typhus fevers, in which  it  is only  occasionally to be met with, and
certainly less frequently than in other fevers.  M.  Planchon regards
it as proceeding mos^frequently from obstructed  perspiration, which
he lays down as its common cause : aud M. Triller, instead of being
a result of weakness,  when in a symptomatic form, asserts that in
various instances it proves critical.^
  * Rat. Med. ir. p. 58, 169.
  I" Dissertation sur la Fievre Miliaire, &c. Tournay. 8vo.
  X Triller et Molinarii Epistolae mutusc de vera exanthematum Miliarium df(-
1. ^rentia. 
GE. 1I.-SP. 1.]      SANGUINEOUS FUNCTION.
389
  In few words, miliaria when idiopathic is an eruption accompanied
with a mild typhus, and a peculiar irritability of the skin.  And when
the same eruption appears as a symptom of some other disease, it is
probable that a like irritability of the skin has been produced by a
course of saburral or acrimonious sweating.
  Of its remote or even exciting causes we  are utterly ignorant.
The stomach seems sometimes to be over-charged;  cold in  the feet
has  been  suspected;  and,  as  observed by M. Planchon, we have
often obvious proofs of obstructed perspiration.  But all these facts
occur in thousands of instances without producing any such  result.
   It is, however, unquestionably a  disease of debility ; and to this
character  our  eye should be directed  in  attending  to  its cure.
Every  thing that heats and  stimulates should be  avoided.  The
bowels should be cleared of all irritating materials by mild laxatives;
and, if offensive  breath or  any  other symptom  should  indicate
defedation of the stomach, an emetic should  be given at  the first.
Cooling drinks, light  bed-clothes and  a  cool atmosphere  will, in
every  case, be  of essential service; and the patient may be allowed
to lay  with his  hands and arms out of bed.
   By  these means alone Dr. Cullen thinks he  has frequently pre-
vented miliary eruption in  lying-in women and others where it
might have been  expected as a concomitant.  But  where  it has
actually appeared, he adds to this  regimen the use of tonic  and
antiseptic remedies, particularly  Peruvian bark, cold drink,  and
cold air.
   Purgatives,  however  gentle, hare been  objected to by  many
pathologists:  but  when not carried beyond  the  strength of  the
patient, they rarely fail to be of service.   " I am  convinced by
experience," says Sir George Baker, " that the prudent application
of this practice to the miliary fever has been of singular advantage:
and it is worthy of observation in this place, that the symptoms of
the measles are often  rendered less formidable, when, during this
disease, the patient has every day  two or three  evacuations by
stool."*
   Something, however,  more specific than this general plan will,
in many instances, be found  necessary.  In his own practice  the
author  has endeavoured not  merely to check  but to change  the
perspiration : and hence, while from an early period  of the disease
he has employed tepid ablution or sponging, which is always highly
refreshing, he  has given small doses of antimonial  powder with
infusion of roses containing a surplus of sulphuric acid:  and has rarely
continued this course for four-and-twenty hours without finding the
sweat  less copious and of a more natural quality.   And where the
languor has been distressing, he has added camphor in the form of
pills, giving a scruple or half a drachm in the course of the twenty-
four hours.
* Med. Trans. Yol. hi. Art. xix. p. 300. 
390
HjEMATICA.
[CL. I1I.-OR. III.
  That the skin is in a state of peculiar irritation is highly proba-
ble from our being sometimes able to excite a like eruption by wear-
ing a shirt of coarse flannel or horse-hair.  And hence Dr. Darwin
gives one example of miliaria, as he  calls it,  «produced  by the
warmth, and more particularly by the stimulus ot the points of the
wool in flannel or blankets applied to the skin, which by cool dress,
and bed-clothes  without flannel, soon ceased."  He has distinguish-
ed  this affection by the  name  of miliaria sudatoria:  but it ought
rather  to be regarded as a variety of intertrigo, or fret.
                        SPECIES  II.

                EMPHLYSIS  APHTHA.

                           STlintsh.

VESICLES GRANULAR,  ROUNDISH,  PEARL-COLOURED ;  CONFINED  TO  THE
  LIPS,  MOUTH, AND  INTESTINAL  CANAL ; TERMINATING  IN CURD-LIKE
  SLOUGHS ; OCCASIONALLY WITH SUCCESSIVE CROPS.

Aphtha is derived from the Greek xirto " accendo" " to burn or in-
flame."  Like the preceding species  this eruption, though at one
time supposed to be papulous, is  now generally admitted to consist
of minute vesicles containing a whitish or  milky  fluid, when matur-
ed : and hence, in a nosological  arrangement, it naturally follows
upon miliaria.
  This disease is found under three varieties, a white, a black, and
a chronic :

x Infantum.           Appearing in  infants soon after birth; and
  White thrush.         often extending from the mouth to the in-
                        testinal canal; mostly with slight febrile
                        symptoms, and white sloughs.
S Maligna.            Accompanied  with great debility of vascular
  Black thrush.         action ; usually ascending from the larynx
                        into the mouth; sloughs  black; fever a
                        typhus.
y Chronica.            Protracted  and exacerbating;  with  great
  Chronic thrush.        emaciation  and  hectio  fever; extending
                        through the whole range of the intestinal
                        canal.

  The disease consists  in  a  peculiar  acrimony that  irritates the
whole mucous membrane, and particularly the mucous glands of the
mouth and fauces, producing minute vesicles and sloughs.  In the se-
cond and third species some  of  the  smaller blood-vessels  are also 
GE. 11.-SP. II.]      SANGUINEOUS  FUNCTION.
391
eroded at the mouth, and hence the sloughs become livid  or nice-
rated.
  All the varieties,  therefore, occur  only under  circumstances  of
considerable debility  ; and hence, while the first is usually found  in
infancy, the two last  are  mostly an accompaniment of low fevers,
old age, or cachexies.
  The white thrush, or  that of infancy, commences in the mouth.
The angles of the lips are  usually first  beset with the  eruption,
probably from their  exertion and fatigue in the act of sucking.
From these it spreads in scattered, papulae  over the tongue and
cheeks, till at length many of the papulae coalesce, and the eruption
appears in patches, or strata.  The fauces become  next affected,
and it descends thence through the oesophagus into the stomach, and
travels in a continuous  line  through  the entire  course of the in-
testines to the rectum, the feces being often  loaded with  aphthous
sloughs.
   In very mild cases the disease restrains itself, or by judicious ma-
nagement is restrained, to the mouth,  and terminates  upon a single
separation of the curd-like crusts.  But it usually  proceeds farther;
and a second, and even a third crop, takes the place of that which
disappears.   The general health is, in the mean time, but little dis-
turbed, though the stomach  evinces acrimony, the pulse  is often a
little quickened,  and the  infant is rendered fractious.  But in an un-
healthy habit, when the  food is innutrient, and the frame weak and
atrophous, the under-surface of the vessels ulcerate,  the ulceration
spreads wider and deeper, a low fever ensues, and the little patient
sinks beneath its malignancy.
   In the mildest form this eruption seems to be  highly acrimoni-
ous ; for the nipple of the nurse is sure  to be affected.  There  is
little doubt, moreover, that the acrimony is specific and contagious :
though, in order  to multiply  itself and preserve  its peculiar  pow-
ers, it seems necessary that  it  should come into  close union with
the same membrane, or a membrane of the same  structure  as that
which originates it.  Hence the  nipple, though corroded  by the
sharpness of the humour, does not produce aphthae, nor does the  ul-
ceration spread beyond the reach of the acrid ichor: but it has been
received by kissing the  infected lips  of  an infant; and has in this
manner propagated itself to  adults as well as to children.
   But, beyond this, we  have good authorities for believing it  at
times to be epidemic.  For not only all the children of  the  same
family, how cautiously soever separated from one another, but ma-
ny of those  of the same neighbourhood, have been known at  times
to suffer from it simultaneously.  Yet whether in this case the epi
demy be  the result of the specific matter of  the exanthem, floating
as an undissolved miasm  in  the atmosphere, or whether any parti-
cular intemperament of the  atmosphere itself predispose  the  body
to the generation of aphtha, is unknown.
    In the cure  of this species our  first object  should  be  to  re-
move all acrimonious materials from  the primae  viae by a laxative 
\
 592                      HJ5MATICA.          [CL.  III.-OR- HI*

 or emetic, or both, and thus, as far as we can conjecture concerning
 it, root out the primary source of disease.  We  must  at the same
 time carefully  examine the health of the nurse of the infant, if the
 infant be at the breast, and particularly as to the nature of the milk,
 and  the freedom  of the nipple itself from  all primary disease, so
 that the child may not have a foundation laid for it in  this quarter.
 If the child be  weaned, we must be particularly attentive  to the na-
 ture of the food, and the mode of its preparation, concerning which
 nurses,  when  left to  themselves, are often too careless.   And we
 have next to prevent the multiplication of the papulae  by syringing
 off the acrimonious fluid as well as we are able with diluting or de-
 tergent gargles, and expediting the separation of the sloughs by in-
 viscating astringents, as bole armenic, alum, borax  or  catechu, in-
 termixed  with mucilage  or honey.  These astringents however
 must not be made very sharp; for  in  this case we shall hurry  off
 the little sloughy curds too rapidly, irritate the tender surface of the
 new skin, and produce a new  crop  of eruption ;  which is perhaps
 excited more frequently by being thus too busy and precipitate than
 by any other means whatever.   If the  disease have descended into
 the  stomach and  intestines, a  mixture of rhubarb and  magnesia
 given occasionally will be  the  best  medicine  with which  we  can
 follow it up.
  The second variety, or black thrush is sometimes found idiopa-
 thically in old age when all the vital resources are failing, and  the
 constitution is sinking apace ; but  it is more commonly a concomi-
 tant  on  acute debilitating diseases ; as in  typhous or malignant re-
 mittents.  Stoll affirms  that in all these cases the disorder com-
 mences not in  the  mouth  as in  infants,  but  in the stomach, and
 works its way both upwards  and downwards ;*  and, from the  pain
 and  cardialgia  that  are  often  complained  of antecedently, there
 seems ground for this opinion.  Birnstiel  makes the same remark,
 and compares the  feeling to that of a tense cord extending from the
 cardia to the navel.t  This variety is also said to be at times epide-
mic and, by some, contagious.  But it should be  observed that in
most of these cases aphtha  has appeared as a concomitant of other
 diseases, and probably as the result of them.  Thus when it is af-
firmed by Muguet to have been decidedly contagious at Paris on a
 particular occasion^ an alarming typhus seems to have been pre-
 sent  also.   Stoll gives the same account of it, but it was then united
 with miliary fever ;§ and on another occasion, when it appears to
 have had pretensions to an epidemic range, it  was combined with
 a prevailing intermittent.||
* Rat. Med. 167.
t Sterblichkeil im Krankenhaus zu Bruchsal.
X Raulin, Von Erhaltung der Kinder.
i Loco citato.
[| Fontanus. Annal. p. 59. 
ttE. II.-SP. II.]      SANGUINEOUS FUNCTION.
393
  In all these cases the mode of treatment must depend upon  the
nature of the particular case.  In the drooping of old age we  can
only palliate ; and our best palliatives will be cordials, as port-wine
negus, or  wine  itself,  and  stimulating nutritive  food : where  the
aphtha is dependent upon some other affection it can only be reme-
died by remedying the parent disorder.
  In very cold northern and especially in cold marshy climates, aph-
tha in one of its varieties  is said to occur  frequently in  all ages,
and often without fever.  As we have already seen that it is very
generally  the result of a reduced slate of health and vigour, this is
by  no  means improbable ;  and the best means of opposing it is
warmth, a pure and unstagnant air, exercise, and a generous diet.
  The third variety, or chronic thrush  seems chiefly also to have
its first seat in the stomach,  or some  adjoining viscus.
  It has been described by  Hillary under the name of aphthoides
chronica, and more lately  by Dr. Latham  under that of cachexia
aphthosa.  It is more frequently found in hot than in temperate cli-
mates, from the  inroad which is so often made upon the strength of
the constitution  by the permanent excitement  of the climate.
  " A slow  hectic fever," says  Dr. Latham, " with  a pulse  weak,
and  a little  quicker than natural, marks  the  commencement of  this
disease.  Pimples on the edges of the tongue, with  superficial blis-
ters within  the mouth  and fauces, next succeed, and a corresponding
heat and soreness of the stomach more or less accompany this  and
every stage of the disease."*  The  whole  intestinal canal soon af-
terwards becomes affected,  and diarrhoea, and not  unfrequently dy-
sentery, are the consequence.   The irritation  then subsides, as
though the disease  had worn itself out, but  there is not  vigour
enough in the constitution to heal the exulcerations ;  and, the original
cause continuing, fresh exacerbations take place, and every symp-
tom is more aggravated ; usually accompanied moreover with a fear-
ful despondency.   These repeated   occurrences gradually exhaust
the system,  and the patient  at length sinks  beneath their persever-
ing assaults.
  Dr. Thomas has given a good account of this affection as it has
occurred from time to  time in the West Indies: and ascribes it to
general relaxation, exposure to cold  combined with great  moisture,
obstructed perspiration, and an acrimony  of the humours.t   And
hence many of its causes, as well as  most of its symptoms,  are those
of the preceding variety.
  During the exacerbations opium  seems to  afford the best relief;
while in the intermissions light bitters  and other  tomes  should be
had  recourse to.  For  the distressing irritation that  often exists in
the throat and rectum, Dr.  Latham  is boid  enough  to recommend
gargles and  injections of diluted litharge-water;  the latter in com-
bination with laudanum.
        * Med. Trans. Vol. v. Art. vi.
        t Modern Practice of Physic, p, 528.
VOL.  II.                    50 
394
H/EMATICA.
[CL. I1I.-0R. Ill-
                        SPECIES III.

                EMPHLYSIS  VACCINIA.



VESICLES FEW  OR A SINGLE ONE ;  CONFINED TO  THE PART AFFECTED J
  CIRCULAR, SEMITRANSPARENT, PEARL-COLOURED ; DEPRESSED IN THE MID-
  DLE : SURROUNDED WITH A RED AREOLA.

This disease attracted attention in  the county of Dorset about forty
or fifty years since, as a  pustular eruption derived from  infection,
chiefly showing itself on the hands  of milkers who had milked cows
similarly disordered.  It had been found to secure persons from the
small-pox ;  and so extensive was the general opinion upon this sub-
ject even at the time before us, that an inoculator,  who  attempted
to convey the small-pox to one who had  been previously infected
with the  cow-pox, was  treated with ridicule.   A formal  trial was
made however,  and it was found that no small-pox ensued.  About
the same time a farmer of sagacity of the name of  Nash, duly at-
tending to these facts, had the courage  to  attempt artificial inocula-
tion on himself;  and the attempt is  said to have succeeded complete-
ly.   Similar facts and numerous examples  of them were according-
ly communicated to  Sir George Baker, who,  having engaged not
long before in a  most benevolent  though  highly  troublesome con-
troversy respecting the cause of the endemial cholic of Devonshire,
was  unwilling,  notwithstanding his triumph,  to tread  again the
thorny paths of  provincial etiology.   Gloucestershire,  however,
another dairy county, had witnessed the same  disease  with similar
consequences; and the same opinion generally prevailing in distant
districts of both counties, afforded proof that the power thus ascrib-
ed to cow-pox was not wholly visionary.*
  Dr. Jenner, then resident at Berkley in  Gloucestershire, pursued
this  hint with great judgment  and unabated  ardour.  He was  at
first  foiled by not distinguishing between the genuine cow-pox, and
an ineffective  modification  of it, or a spurious disease of nearly a
similar appearance, to which the same  animal  is subject,  but which
is no preservative against the small-pox; and found another difficul-
ty in determining the period of time within which the vaccine virus
maintains its  prophylactic  power.  Having at length,  however,
made himself  master of the distinctive characters of the genuine
vesicle, he  ventured to publish the discovery in  1798, and  to re-
commend inoculation with the virus of vaccinia as a substitute for
variola.  The  result is  known to  every  one  : the discoverer has
been justly and liberally remunerated by parliament, and vaccine
V: Evidence delivered before the Committee of the House of Commons. 
 GE. II.-SP. III.]        SANGUINEOUS  FUNCTION.             39.r)

 inoculation has  passed with  rapid progress over every quarter of
 the world, from the arctic circle to the extremes of Asia and Africa ;
 and been adopted by civilized and uncivilized nations, by blacks as
 well as by whites, by the Fin, the Hottentot, and the Hindoo.
   The disease in its present state may be said to embrace the four
 following varieties:              •
 x Nativa.                       Genuine cow-pox  as it ordinari-
   Natural cow-pox.                 ly appears on those who  ac-
                                    cidentally receive it from  the
                                    affected cow.
 5 Spuria.                         An  ineffective  modification  of
   Spurious cow-pox.                .cow-pox, or a different but re-
                                    sembling disease  incapable of
                                    preserving against small-pox.
 y Inserta.                        The genuine cow-pox as it  ap-
   Inoculated Cow-pox.              pears on inoculation.
 $ Degener.                      Cow-pox degenerated in its spe-
   Degenerate Cow-pox.             cific  power  of preservation
                                    from unknown causes.

   In the natural form of  cow-pox, or as  immediately  received by
 milking or otherwise handling a diseased animal, the  vesicles  are
 more or less  numerous, and appear  on the hands or such parts as
 have been in contact with the affected udder; of a blueish tint;  the
 fluid at first limpid; afterwards opake and purulent; often with  en-
 largement of the auxiliary glands, and considerable fever.
   Most frequently the vesicles  make their appearance  about  the
 joints, or  extremities of the fingers; their figure is  circular, and
 there  is a slight dip from the circumference to the  center.  The
 fever opens with its usual  symptoms  of lassitude, pain in the head,
 limbs, and loins, rigor, vomiting and a quickened pulse ;  the head
 sometimes continues  affected after  these  preparatory signs  have
 gone  off,  and  is even accompanied with  delirium.   The  inflamed
 and ichorous tubercles having suppurated, burst in  three or four
 days from distension, and become troublesome sores, healing slowty,
 and occasionally assuming a phagedenic appearance.  The fever in
 the meanwhile abates and ceases altogether about the seventh day.
 The fluid discharged from  the ulcers  is highly contagious; and the
 eye-lids, lips, nostrils,  or any other part of the body,  is sure to  be-
 come inoculated with it it  scratched or rubbed with the fingers  ac-
 cidentally charged with the matter.
   In the affected cow itself the tubercles  are still larger, or rather
 consist of vesicles surrounded by a broad and  circular  erythema:
 the animal droops considerably  and  yields but  little  milk.   The
 ulcers are  foul and often obstinate.
   In the spuriou* cuw-pox, or the disease  to which cows are sub-
ject, that bears a near resemblance to  the genuine, and is often con-
founded with it though destitute of its prophylactic power, the vesi-
• les are le«« uniformly circuhr  : purulent from the first: without 
396
HjEMATICA.
[CL. UI.-OR. III.
the blueish tint;  with little or no  central depression.   Whether
this, in the animal itself,  be strictly a variety of a common species,
or a distinct  species of a common genus, has not been  accurately
determined.  But  it is now fully ascertained  that this  affection of
the cow produces  no security by inoculation, and was the  cause of
much confusion and  many failures at first, and possibly  may be of
some in the present day.
  In the inoculated cow-pox from genuine virus, the pathognomic
signs are  the following:  vesicle  single confined to the  puncture;
cellulose; blueish brown  in the middle ;  fluid clear and colourless
to the last; concreting into a  hard,  dark-coloured  scab after the
twelfth day.
  In propagating the disease from the inoculated vesicle, the fluid
should be taken before the ninth day, and from as early a period as
it can be  obtained.  After the ninth day it is usually so inactive as
not to be depended upon.
  If the fluid be not transparent, it forms a decisive proof either
that it is spurious or imperfect.  The puncture should  be made as
superficially as  possible ; for if much  blood be drawn the fluid may
become so diluted as to be rendered ineffective, or may be entirely
washed  away.
  As small-pox  by inoculation is uniformly a far milder disease, and
accompanied  with a smaller crop of pustules than when received
naturally, cow-pox by inoculation undergoes a like change.  There
is sometimes  a  little  increased quickness of pulse and constitutional
indisposition; and, in very rare instances, a few pustules have been
thrown  forth around the areola  or even on the limbs ; but  with
these occasional exceptions, the eruption, as already noticed, is con-
fined to the single vesicle  produced  by the puncture,  and there is
scarcely any  perceptible  fever.
  The general progress  is as  follows.   The puncture  disappears
soon after the insertion of the lancet: but on the third day a minute
inflamed spot becomes visible.  This gradually  increases in  size,
hardens, and produces a  small circular  tumour slightly elevated
above the level of the  skin.  About the sixth day, the center of the
tumour  shows  a discoloured speck  formed by the  secretion of a
minute quantity of fluid ;  the speck augments in size  and becomes a
manifest vesicle, which continues to fill  and to be distended till  the
tenth day: at which  times it displays in  perfection the peculiar fea-
tures that distinguish it from the inoculated variolous pustule.   Its
shape is circular, sometimes a little oval;  but the margin is always
well defined,  and never rough or jagged ;  the center dips instead of
being polarised, and i9 less elevated than the circumference.
  About the  eighth day, when the vesicle is completely formed,  the
disease  exhibits something of a constitutional influence ; the arm-pit
is painful, and  there is perhaps a slight head-ache, shivering,  las-
situde, loss of appetite, and increase of pulse.  These may continue
in a greater or less degree for  one or two days, but always subside
spontaneously,  without leaving any unpleasant  consequence.   Dur- 
©E. II.-SP. HI.]      SANGUINEOUS FUNCTION.
397
ing the  general  indisposition the vesicle in the  arm becomes sur-
rounded with a circular inflamed halo or areola, about an inch or an
inch and a half in diameter, which is the pathognomic proof of con-
stitutional affection, how slightly soever the internal symptoms may
show themselves.  After this period the fluid in the vesicle gradual-
ly dries up ;  the surrounding blush becomes fainter, and in  a day
or two  dies away  imperceptibly ; so that it is seldom to  be distin-
guished beyond  the thirteenth day from inoculation.  At  this  time
the vesicle hardens into a thick scab of a brown or mahogany col-
our ; and if not separated antecedently by violence or accident, falls
off spontaneously in about a fortnight, leaving the skin beneath per-
fectly sound and uninjured.  The entire progress of the inoculation
scarcely opens a door to any medical treatment whatever.   No pre-
paratory steps are called for, as in small-pox ;  and all that can be
necessary is  a dose or two of some aperient medicine if the con-
stitutional indisposition should be severe or troublesome.
   There  is  a  variety of vaccinia, denominated degenerate  cpw-
pox by  Dr. (now Sir Gilbert) Blane in his  evidence  upon this sub-
ject before the Committee of the House of Commons, of which the
following may be  regarded as the character.   Produced by inocula-
tion ; vesicle amorphous or uncertain ; fluid often straw-coloured, or
purulent;  areola  absent, indistinct or confused with the vesicle ;
scab formed  prematurely.   The cause of this degeneracy has not
yet been sufficiently pointed out; but it is now well ascertained that
inoculation from  this species will not prevent the  small-pox; and
hence a variety  of mistakes in the early practice before the fact was
discovered.
   Vaccine virus seems to undergo a spontaneous alteration in a cer
tain period of time, whatever be  the caution  with which it is pre-
served ; but  there are some circumstances that seem to favour this
alteration  more, than others, although we know but little of the
nature of these circumstances.  Even in passing through the human
subject in the form of inoculation, it appears  to be modified  and to
be rendered  milder :  for a person immediatety  inoculated from the
affected cow uniformly suffers more than one person inoculated from
another.   It has been proved however that the fluid  loses nothing
of its specific power after a long series of transmissions from in-
 dividual to individual; for cows have been inoculated with it in this
state of repeated  descent, and have exhibited the disease in all its
natural violence.   Yet if the second  variety be a modification of
this disease, and not  a distinct eruption, it affords proof of a change
in the  qualities of the virus taking place  in the animal itself from
 some undiscovered cause.
   It ought also  to be stated  that the  genuine  cow-pox itself has not
 proved a permanent prophylactic in  particular habits  or idiosyn-
 crasies, of the nature of which however we know nothing.  But the
 cases in which  it has failed are very few ; and in  almost every in-
 stance  the small-pox occurring afterwards seems to have been chang-
 ed from its natural course, and rendered milder and of shorter dura- 
398
HjEMATICA.
[CL. 1II.-0R. III.
tion;  the pustule rarely exceeding the fifth day before it has begun
to turn; and the  fluid generally passing at once from an ichorous or
limpid into a concrete or indurated state without the intervention
of pus.  While therefore the absolute infallibility of the prophylac-
tic power of cow-pox inoculation  is  no longer  to be  maintained,
enough  still  remains  in support of its pretensions of being one of
the most important  discoveries in medicine, and one of the greatest
blessings that  has ever been conferred on mankind  ; as has been
sufficiently  proved in an admirable article published by  the French
Imperial Institute, and drawn up by three of its brightest ornaments,
M. M. Berthollet, Percy,  and Halle, of the date of August 17, 1812.
   For the failure of success in many hundreds of instances that have
been  triumphantly brought forward by its  enemies, there is no dif-
ficulty in accounting;  but there are others  which are not to be dis-
posed of in the same manner,  and  which irrefragably establish  its
inefficacy from causes that elude all explanation.  The  real merits
of the case are summed up with great candour and judgment in the
following  passage of the last report of our own National Vaccine
Establishment. " After every reasonable deduction, we are compel-
led to allow, that too many cases still remain on undeniable proof to
leave any doubt  that the  pretensions of vaccination to the  merit
of a perfect and exclusive  security in all  cases  against small-pox
were admitted at first rather  too  undeservedly.   Yet  the value of
this  important resource  is not  disparaged in our judgment:  for,
after  all, these cases bear a very small proportion to the number of
those who are effectually protected by it."—Eight only are stated
by the metropolitan stations out of nearly  67,000 vaccinated since
the establishment of  the board: and " we have undoubted proofs
from  experience, that where  vaccination has been performed per-
fectly, small-pox occurring after it is almost  universally a safe dis-
ease ; and though ushered in by  severe symptoms, has hardly  ever
failed to be  cut short before it had reached that period  at which it
becomes dangerous to life."*
   The only case that has ever occurred  to myself in which vacci-
nation has not seemed to produce any influence whatever upon the
character of subsequent small-pox, is one I am attending  while writ-
ing these  pages.   The patient is  Mr. Alfred Phillips,  of  Christ's
College, Cambridge, about  twenty years of age, who was vaccina-
ted when an infant by Dr. Jenner.  The eruption is of the distinct
variety, but, for  this variety, as full  as possible  over the whole of
the face, body,  and limbs ; the  fever has been very considerable,
and every part is severely hot, sore,  and tumefied, so that the eyes
are nearly closed, and always opened with difficulty in the morning:
and the  spaces between the pustules, which, however, are  few and
small, are of a fiery red.  The pimples made their appearance on
the third day from the accession  of the fever;  they have maturated
regularly, and are at this time, which forms the eighth day of erup-
* Report of April 12, 1821. 
GE. H.-SP. III.]       SANGUINEOUS FUNCTION.             399

tion, very large, and a, few of them just beginning to turn brown on
the apex, so that it will not be necessary to follow up the descrip-
tion any further.
  It is  possible that  there are other animal poisons which may in
like manner act as a prophylactic against small-pox, and destroy the
susceptibility to this disease in the human frame : for the 6ame effect
seems to have followed upon inoculation with the sanious discharge
from the heels of horses afflicted with the disease called grease. And
Dr. Jenner, who, on  his first directing his attention to the nature
and effects of cow-pox, applied himself also to this subject, felt per-
suaded  at that period that the two fluids of  cow-pox  and  of grease
from  the heel  of  a horse, are precisely the same, and capable of
affording a like emancipation.   He  conceived the sanious fluid of
the grease to  be the  original disease, and the cow-pox in the cow
itself to be nothing more than a casual inoculation produced by the
cow's lying down in a meadow where the affected horse had been pre-
viously feeding, and her udder coming in contact with the discharge
which had dripped on the grass and lodged  there: and he endea-
voured to show the identity of the fluids by  the identity of their ef-
fects in respect of the small-pox.—So far as  can be judged from the
few cases before us,  performed  indeed in  different  countries, but
still few in respect to the number necessary to  establish a positive
proof, grease-pox  seems to have succeeded as well as cow-pox ; and
it is hence possible that there may  be, as already  observed, other
animal poisons possessed of a similar power.   But it is not necessary
to search for them;  none can surpass, and  none  be  expected to
equal, the cow-pox process in respect to cleanliness, simplicity, and
little disturbance to the system;  while on  the contrary,  the  mere
idea of using the matter of grease from the horses'  heel, excited
from the first so deep and extensive a disgust, that cow-pox inocula-
tion had nearly fallen a sacrifice from the  supposed union of the
two diseases.   It was fortunate, therefore, for Dr. Jenner, and the
triumph of his discovery, that  a minuter attention to the  subject
gave sufficient proof that there was no  foundation  for his opinion :
and that, whatever be the prophylactic power of the  matter of the
disease called  grease, this disease is  by no means the origin of the
natural cow-pox, and has no connexion with it. 
400                    HiEMATICA.           [CL. Hl.-Oft. III.


                        SPECIES  IV.

              EMPHLYSIS VARICELLA.

                        OTateMloj:.

VESICLES  SCATTERED  OVER THE  BODY ;  GLABROUS ; TRANSPARENT ;  PEA-
  SIZED ;  IN SUCCESSIVE CROPS;  PELLICLE THIN ;  ABOUT THE THIRD DAY
  FROM THEIR APPEARANCE BURSTING AT THE  TIP, AND CONCRETING INTO
  SMALL PUCKERED SCABS, RARELY LEAVING A CICATRIX.

The water-pox appears  under the three following varieties, distin-
guished chiefly by the shape of the pimple :
x Lentiformis.             Lentile-shaped, or irregularly circular,
  Chicken-pox.               flattened at the top ; fluid at first pel-
                             lucid, then whitish ; afterwards straw-
                             coloured.
a Coniformis.               Vesicles  acuminated; fluid  pellucid
  Swine-pox.                 throughout.
y Globularis.              Vesicles  globular and larger ; fluid at
  Hives.                     first whey-coloured,  afterwards yel-
                             lowish.
 3 Corymbosa.             Vesicles  clustering  upon  a  common,
  Clustering water-pox.       but broader base ;  redder at the first,
                             and later  in  appearance;  febrile
                             symptoms outlasting  the eruption.

  Several of the  varieties are sometimes  intermixed, and the fluid
about three days after the eruption occasionally becomes  thickish
as well as yellowish in the first and third,  and possesses a purulent
appearance; whence, in various instances,  they have been mistaken
for  the small-pox.   The eruptive fever in chicken-pox is also some-
times considerable; and hence, another cause of the same mistake,
a mistake that has  not unfrequently  led to serious  and even  fatal
consequences,  by putting those u ho  have  had the  disease off their
guard against variolous  infection.  And where this error has been
committed, and the small-pox  has  afterwards been  received, it has
led  to a second mistake, by inducing the patient to believe that he
has had the small-pox a second time.
  The two diseases, indeed, were  long confounded by  physicians of
the highest character : they were regarded as alike  by Morton ; and
even in Sauvages, varicella is described under the name  of variola
lymphatica.  It is now, however, thoroughly ascertained to originate
from a peculiar specific contagion ; and  the characters by which it is
sufficiently distinguished from small-pox are, that its fluid, except in
a few anomalous cases, is limpid  throughout; and  that as  early  as
the third  or fourth day from  the eruption it concretes into crusts, 
CE. H.-SP. IV.]
SANGUINEOUS FUNCTION.
401
 which are thrown off without indenting the cutis:  while in small-
 pox the  fluid consists of pus as soon as formed, and does not con-
 crete  into  crusts  till  the  seventh  day,  and  often  much later.
 Like the small-pox it does not attack the same person a second time,
 excepting in  a few anomalous constitutions, that establish rather than
 oppose the general rule.  " I wetted a thread,"  says Dr. Heberden,
 u in the most concreted pus-like liquor of the chicken-pox which I
 could find, and  after making a  slight incision, it was confined upon
 the arm of one who had  formerly had it: the little  wound  healed
 up immediately, and showed no signs of any infection."*
   In the ordinary course  of the first  three  varieties the pyrectic
 symptoms  are  so  slight as not to require medical  attention: and
 sometimes there is no fever whatever.  The eruption makes its ap-
 pearance chiefly  on the back,  and  is often  confined to it; and the
 general number of vesicles vary from 20 to 200.   I have sometimes,
 however, known the eruption preceded by  almost as severe febrile
 signs of shivering, sickness, head-ache, and pain in the limbs, as
 that of small-pox, but the  symptoms have always subsided when the
 vesicles have appeared.
   In this case an active purge should  be administered, succeeded by
 some diluting drink ; and the patient  should be confined  to a quiet,
 spacious and well ventilated room, with a cool dress, till the febrile
 symptoms have left him.
   For the fourth variety I am entirely indebted to the observant
 and indefatigable eye of Dr. Heberden; for it  has  never occurred
 to me, nor is it to be  found in the tables of the Nosologists.   " This
 disorder,"  says he, " is preceded for three or four  days by  all the
 symptoms which forerun the chicken-pox, but in a much higher de-
 gree.  On the fourth  or fifth day the  eruption  appears,  with very
 little abatement of the fever;  the pain likewise of the  limbs and
 back still  continues, to  which  are joined pains ot the gums.   The
 pocks are redder than the chicken-pox, and spread wider, and hard-
 ly rise so high, at least not in proportion to their size.   Instead of
 the little head or vesicle of the serous matter, these have from four
to ten  or twelve.   They go off just like the  chicken-pox, and are
 distinguished  from the small-pox by  the same marks, besides which
the continuance of the pains and fever after the eruption,  and the
 degree of both these,  though there.be not above twenty pocks, are,
as far as I have  seen, what never happen in the small-pox."t
* Medical Transactions, Vol. i. Art. xvn.
 t Med. Trans, ut supra.
VOL.  IT.
51 
402                      H.EMATICA.          [CL. HI.-OR. II*'
                        SPECIES V.

              EMPHLYSIS PEMPHIGUS.

             Bfesfcttlar,  or IflaHrcrg  jfttev.

VESICLES SCATTERED  OVER THE BODY ; TRANSPARENT ; FILBERT-SIZED ,'
  WITH  A  RED INFLAMED EDGE,  BUT WITHOUT  SURROUNDING BLUSH  OR
  TUMEFACTION ;  ON BREAKING,  DISPOSED TO ULCERATE ;  FLUID PELLU-
  CID, OR  SLIGHTLY COLOURED ;  FEVER A TYPHUS.

The term pemphigus is derived from the  Greek mftq>t%, " flatus,
bulla,'1 and hence inflation, bladder, bubble.   The idea of flatulency,
however,  is seldom connected with this disease in modern  medi-
cine, though very generally in ancient.  The term, in the sense in
which it is now commonly understood, was, perhaps, first employed
by Sauvages; and  has  since  passed into  common use.  It is still
doubted by  many whether pemphigus is entitled to be  considered
as a distinct  and idiopathic disease; and whether all  its varieties
and modifications may not  resolve  themselves  into certain pecu-
liarities of  erysipelas or pompholyx, the  latter of which  con-
sists  of similar  vesicles, or bullae,  without fever;-or  into mere
symptoms  of typhus or plague.  Gulbrand appears to have been of the
former opinion; and hence he has denominated the disease erysipelas
vesiculare :* Dr. Cullen seems to have been of the latter at the time
of drawing up his definition, and still  later,  at that of drawing up
his First Lines, in consequence of which he dismisses  it in a single
paragraph as an affection  concerning which he  can  say nothing.
But the fourth edition  of his  Synopsis contains a subjoined  note,
which  intimates that his opinion was altered in consequence of his
having  seen a patient  shown him by Dr. Home,  and  who  was la-
bouring under  this disease, as an idiopathic affection, at the  time.
And  when to this we  add the  authority, not merely of the  earlier
writers, Bontius, Seliger, and  Langhans, but of Withers, Clarkson,
Christie, Ring, Braune, and Dr. Stewart of Aberdeen, it would be
unpardonable not to allow it a distinct place  in a general system of
nosology.
  Upon a  careful review it appears  to offer the three following va-
rieties,  which  run  parallel with  those of Dr. Willan, though not
exactly taken from him :—

x Vulgaris.                    Vesicles  appearing on the second
  Common vesicular fever.       or third day, occasionally not till
                                the  fifth or sixth;  in  successive
                                crops;  often extending over the
* Act. Soc. Med. Hafn. Tom. i. 
ViE. II.—SP. V.]     SANGUINEOUS  FUNCTION.
403
                                mouth and intestinal canal; fluid,
                                on bursting, yellowish ; some of
                                the vesicles  livid,  with a livid
                                base.
                              Preceded by tumefaction of the neck
                                and throat; vesicles chiefly seat-
                                ed on the fauces and  conglobate
                                glands ;  occasionally   producing
                                abscesses; highly contagious.
                              Vesicles  irregularly  oblong, with
                                livid edges and commonly flatten-
                                ed tops; appearing successively
                                on different parts of the surface in
                                infants a few  days after birth; on
                                breaking, purplish.

  The first variety, or common pemphigus, is the pemphigus ma-
jor of Sauvages, a very marked case of which  was given in a com-
munication of Dr. David Stewart to Dr. Duncan of Edinburgh.*   It
appeared on a young private  of the  seventy-third regiment, who
had for a fortnight or three weeks antecedently been unwell from
a sudden  retrocession of measles  produced by  an exposure to cold,
and afterwards to a damp unventilated apartment.  He  was recem
ed into the hospital at  Aberdeen  April 15, at which  time he com-
plained of head-ache, sickness, oppression about  the precordia, thirst,
sore  throat, difficulty of swallowing; his tongue was foul, his skin
hot, pulse from 110 to 120,  rather depressed.  The whole surface
was interspersed  with  vesicles of the size, of an ordinary walnut;
especially the breast and arms.  In the interstices the  appearance
of the  skin  was natural; and the  distance from one  vesicle to an-
other was from  half an inch  to a hand's breadth or more.  The
disease did not appear to be contagious, as the patient was a solitary
instance of it, both where he resided before and after his reception
into the hospital.   His  chief medical treatment  consisted in bark
and port-wine with acidulated drinks : many of the vesicles broke,
and discharged a bloody and most  offensive ichor; the cutis, upon a
rupture of the vesicles, was for the most  part  sound, of a deep red
hue, and  in some  places livid.  A new cuticle was gradually  pro-
duced : and on April 27, being  twelve days from his  reception into
the hospital, he was dismissed perfectly cured.
   In this  case the bullae do not seem to have  reached  below  the
throat in  an internal  direction ; nor  lower than this region in the
severer case  described ]oy Seliger.   In the first instance, the vesi-
cles appeared abruptly, and had bursted  and were healed in seven
or eight days.  In Seliger's case they issued more gradually, and in
successive crops, ran through a longer period, and were  not healed
till the twenty-first day.t  In a case  apparently of the  same kind,
* Edinb. Med. Comment. Vol. vi. p. 79.
t Ephein. Act. Nat. Cur. Dec. i. Ann. viii. Obs. 58.
g Glandularis.
  Glandular vesicular fever.
y Infantum.
  Infantine vesicular fever. 
404
HjEMATICA.
[CL. IH.-OR. Ill,
published by Dr. Dickson in the Transactions  of the Royal  Irish
Academy, there is evident proof of their having extended from the
fauces throughout a considerable part of the alimentary canal:  here
also the vesicles appeared in successive crops, especially  on the
ninth,  tenth, and thirteenth day, each crop continuing four or five
days before it bursted;  the  fever was accompanied with  delirium,
but abated on the fifteenth day on the appearance of the catamenia,
and the bulla; healed in succession without any trouble.*  None of
these appear to have  been contagious.
   1 cannot speak of pemphigus from personal knowledge; but in all
the above instances the fever was of a low or typhous type ;  and
the disease seems to have approached the  nature  of erysipelas, as
it was  treated successfully by the means usually employed for the
latter.
   For  what little knowledge we possess of  the second or glandular
variety, the contagious pemphigus of Dr. Willan, we are chiefly
indebted to Dr. Langhans, a Swiss physician, who observed it in the
spring and through the summer of 1752 in  the low-lands of his own
country.!  It commenced with a sense of tension in the fauces,  and
a slight pain spreading behind the ears to the anterior part of the
thorax, accompanied with the symptoms that mark the first stage of
fever,  but not succeeded by a hot  fit.  A  greenish bilious  matter
was sometimes thrown  up  from the  stomach,  and the pulse was
feeble.  The neck swelled  externally and internally about the fau-
ces, bullae were  observed of the size of a filbert, producing  little
pain,  and containing  a yellow  ichor  of an offensive  smell.   Soon
afterwards similar vesicles were found scattered sparingly over the
body and limbs,  which, if not broken or opened,  collapsed in the
second, third, or  fourth day,  and dwindled  into  whitish  crusts.
During this period the tumour of the neck often suppurated, or
other suppurating tumours  formed in some  of the conglobate or
conglomerate glands,  as the parotid, axillary or inguinal; and the
virus  of the disease  being  thus  discharged  by  different  outlets
on the  surface of the  body, the  patient recovered.  But  if before
this translation to the surface,  there  were a sense of weight  and
anxiety about the tho'rax,  a large  abscess was formed internally,
and on its bursting,  the patient died from suffocation.   Or if the
matter, lodged in the  external vesicles, were by accident repelled
before  any glandular suppuration took place, he died almost as sud-
denly.
   M. Langhans compares this  disease to syphilis, but apparently
with little reason ;  and Dr. Cullen and Dr. Frank with not much
more to rosalia paristhmitica.  The cause, like that of the sweating-
sickness, is altogether unknown, and like  this  disease also,  after
having  ravaged  with great  fatality for a certain but a shorter pe-

                * Vol. I. 1787.
                t Act. Helvet. Torn. n. p. 260. 
GE. II.-SP. V.]     SANGUINEOUS FUNCTION.               405

riod of time,  happily  for Switzerland,  and perhaps for all Europe,
it  vanished, and  has  been heard of no more.  Sauvages,  indeed,
quotes a description of pemphigus from Thiery,  which, by  some
writers, has been supposed to be the same ;  but  the  account is so
brief, and at the same time so loose and indistinct, that it is impos-
sible either to arrange or reason about it.
  The glandular pemphigus of Switzerland, according to M. Lang-
hans,  was both contagious and epidemic ; so contagious, indeed, as
to spread through numerous families  with great rapidity, and so
malignant that all persons affected by it died.  This last assertion,
however, compared with what follows,  appears to be a little  over-
charged ; for the author proceeds,  as already  observed,  to  point
out under what  circumstances patients recovered  from it; and lays
down a remedial process,  which, " though at  first," says he,  " I
employed it with anxiety and hesitation, I can  now with pleasure
recommend to all persons labouring under the complaint with the
most sanguine hope that it will effect a speedy cure."
   This successful practice,  as in the sweating sickness, consisted
in exciting a strong determination to the surface  by active sudori-
fics ;  and at the  same  time supporting the strength with  camphor
and other cardiacs.   He commenced his process,  however, by ve-
nesection, which was sometimes repeated,  and,  where there was
danger of an abscess in the lungs,  unquestionably  with great  judg-
ment.
   The infantile pemphigus appears, as already  noticed, most com-
monly a  few  days after birth; but in one case  adverted to by  Dr.
Willan, as late as ten  months  after this period.  The vesicles show
themselves on the neck, upper part of the breast, abdomen, groin,
scrotum,  and  inner parts of the  thighs.   They  arise  successively,
break, and expose a surface  that  heals with difficulty; and  more
generally enlarges its boundary, and wears  out  the  little patient
with pain, restlessness, and want of sleep.  Warm cordials, as cam-
phor  and the aromatic confection, with  a  little  port-wine-negus,
form the  best means of supporting the strength,  and giving success
in the struggle : and laudanum must be had recourse to where  the
want of sleep requires it. 
406                     1LEMAT1CA.           CCL' in--°R' lHl


                        SPECIES VI.

             EMPHLYSIS  ERYSIPELAS.

                   St.  &nthon&z iFCrc

vesication  diffuse ;  IRREGULARLY circumscribed ;  APPEARING  OS A
  PARTICULAR PART  OF THE BODY,  CHIEFLY  THE FACE,  ABOUT THE
  THIRD DAY ;  WITH TUMEFACTION, AND ERYTHEMATIC BLUSH :  FEVER
  USUALLY ACCOMPANIED WITH SLEEPINESS, OFTEN WITH  DELIRIUM.

In describing the genus erythema,  I endeavoured to  point  out a
distinctive line  between  that  inflammation  and erysipelas,  which
are so often intermixed and confounded even by good writers; and
observed that the first bears the  same analogy to phlegmon, as
the last to small-pox.   Phlegmon  is  local  inflammation tending to
suppuration ;  erythema, local  inflammation lending to vesication:
small-pox is an idiopathic fever producing  a  phlegmonous efflores-
cence ; erysipelas an idiopathic fever producing erythematic efflo-
rescence.   Small-pox is always contagious; erysipelas  occasionally
so: phlegmon and erythema have no such  tendency.
  The varieties of this species are  very  differently given by diffe-
rent writers;  by many of whom they are  multiplied  most unneces-
sarily. Dr. Cullen makes even  the herpes zoster, or shingles, a
variety; but this is strangely to confuse simple cutaneous diseases
with idiopathic fevers.  For that erysipelas, when genuine,  is an
idiopathic fever dependent upon or  productive of a  specific virus
is clear, because it has often, though not generally, been found con-
tagious, and is capable  of propagation by inoculation.   " When the
acrimonious lymph," observes  Dr. Willan, " contained in the  phlyc-
taenae  or vesications of a genuine erysipelas, is inoculated or casually
applied to any slight wound in a person otherwise healthy, it pro-
duces febrile symptoms, with a red and painful but diffuse swelling,
analogous to that of the  disease from which  the virus was deriv-
ed."*  And he has added a case, in  which the mother of a young
girl severely affected with this disease appears to have received it
in consequence  of having nursed her.
  Dr. Wells has strengthened the doctrine of its contagious proper-
ty by a variety  of facts and cases that can  scarcely, I should think,
be read by any  one without conviction.!   One of his example* ex-
tends  to four individuals, who received the disease in succession af-
ter direct contact or near approximation with each other;  and ano-
ther gives us a  like line of not less than six in descent, all of whom,
* On Cutaneous Diseases, p. 514.

+ Transact, of Soc. for the Improvement of Med. and Cbir. Knowledge, Vol. n.
 91"!                                                 ° ' 
GE. II.-SP.  VI.]      SANGUINEOUS FUNCTION.               407

indeed, he  did not attend personally, but the history of whom, as
communicated to him by one of the affected, was confirmed by Dr.
Pitcairn, who had been consulted by two of the rest, and was privy to
the general fact. Dr. Pitcairn also communicated to Dr. Wells the fol-
lowing highly important statement in addition : " A lady immediately
after delivery was attacked with a fever which was accompanied with
an affection of her skin somewhat like  erysipelas ;  her child, about
three days  after its birth, was seized with that species of erysipelas
the French call la gelure, whiph first appeared about the pudenda, and
afterwards  extended itself to other parts of the body, among the rest
to the face.   Both the lady and her child died after a few days illness ;
and about eight days after the death of the child, the lady's mother
and servant maid, both of whom had attended it during its illness,
were attacked with erysipelas of  the face, from which both of them
recovered."   The  opinion of Dr. Baillie, as communicated to Dr.
Wells  on another occasion, is to the same effect; to which Dr.Bail-
lie seems to have been  more especially led, by having observed in
" a part of the years 1795 and 1796, that the erysipelas of the face
was much more frequent in St. George's Hospital  than he had  ever
before known it to  be ;  that many persons were attacked after they
came  into the hospital, and that  the number in a  particular  ward
was much  greater than in any other."
   This last remark seems to give some countenance to the further
opinion, that erysipelas becomes  occasionally an epidemy, or ope-
rates through the medium of the  atmosphere, ;is weJl as by direct
contact: though whether the atmosphere, in this case, be impreg-
nated with the specific miasm of the disease, or merely predisposes
the body to a more ready generation of it, has no more been deter-
mined than in the case  of various  other exanthems that  evince  a
like power.  Dr. Parr asserts broadly, " we have four times seen it
epidemic;  and more than once we have had reason to suspect that
it was communicated by  infection."*
   At first sight it might  seem easy from these accounts to subdivide
erysipelas into the  two  varieties  of contagious and uncontagious;
but as  it is  most probable that the power of communication depends
alone upon the peculiar diathesis  of the person who receives it, as
being endowed with a susceptibility of the  disease not possessed by
others, we  can make nothing of this discrepancy :  and shall hence
examine it under the following varieties founded  upon other cir-
cumstances :

x Locale.                  Limited to a particular part;  the cuti-
   Local erysipelas.           cle raised into numerous aggregate,
                             distinct cells; or the cells running
                             into one  or more blebs or large blis-
                             ters.
* Diet, in verbo. 
408
ha;matica.
[CL. HI.-OR. III.
 € Erraticum.               Travelling  in successive  patches from
   Erratic erysipelas.         part to part  : the earlier patches de-
                             clining as new  ones make their  ap-
                             pearance.

   The local erysipelas generally exhibits  itself on one side  of  the
 face, or on some  one of the limbs.  In the former case the disease
 begins with coldness and shiverings, which alternate with irregular
 flushes of heat, and other symptoms of pyrexy.  Dull  aching pains
 are felt in the head, neck, and back.  The swelling usually appears
 in the course of the second night or the third day ;  though I have
 sometimes  known it take place within a few hours  after the at-
 tack ;  the redness disappearing when pressed  upon  by the finger,
 but returning as soon as  the pressure is removed.  The eruption
 fixes itself on one side of the nose, or the  cheek, temple, or fore-
 head : is of a dark red colour, smooth and  soft, and attended  with a
 sensation of heat and tingling.  The redness and swelling extend
 gradually over the affected side  of the  face; and spread, in  some
 cases to the scalp, and to the side of the neck or the upper part of
 the breast.   Hence the face appears much disfigured;  the mouth is
 drawn to one side; the eye-lids are turgid, and  close  up the eye,
 the fever increases, and is often  attended  with  delirium.  On  the
 fourth and fifth day vesications arise on  different parts of the dis-
 eased surface, especially about .the  centre ;  but with  an increase
 rather than a diminution  of the fever.  The vesicles or bullae  are
 of different sizes, and have an irregular base.   The fluid contained
 in them is at first clear and  watery: it  afterwards becomes  straw-
 coloured or opake,  occasionally slightly livid,  without  losing its
 transparency.  The cuticle gives way in a few places, and the fluid
 oozes through the cracks.  About the eighth or ninth day, and some-
 times sooner, the redness changes to a brown or yellowish hue, the
 bullae subside, and the cuticle dries  and  desquamates or scales  off.
 Occasionally both sides of the face are affected at the same  time;
 though generally the morbid half is separated from the sound by an
 exact line drawn  across the forehead, down the middle of the nose
 to the chin.   The fever subsides about the eight or  ninth day,  hut
Sometimes after its cessation it returns suddenly with as much vio-
lence as at first, and continues two or three days longer.   A sanious
fluid approaching the nature  of pus, and which by De Preval* and
 other writers seems to have been mistaken for pus itself, is  some-
 times found in parts of the vesication: and from this circumstance
 Dr. Cullen has distinguished one variety of the disease by the name
of erysipelas phlegmonodes; and  has been copied by  Dr. Willan.
But a genuine phlegmon  is never met with in erysipelas.  " A cir-
cumscribed cavity," says Mr. Pearson, " containing laudable  pus is
never seen in the legitimate erysipelas.   Where a purulent effusion
 happens in any considerable degree, it affords, when the part is  ex-
amined, a sensation similar to that excited by a quagmire or morass.
'■  Journ. de Mod. Tom. i.i. p. 315.—Eph. Nat. Cur. Dec. n. Ann. iv. p. 52. 
GE. H.-SP. VI.]
SANGUINEOUS FUNCTION. '
409
In that sort of suppuration, which sometimes supervenes to erysipe-
las, the cellular membrane suffers great injury, and not uncommonly
the part is in a gangrenous condition."*
  When the head is the seat of disease, it occasionally swells to an
enormous magnitude, and, acccording to De Roma, the malady  has
proved fatal.t   The disturbance of the constitution is  less  violent
when the erythema appears in the extremities.  The  limbs most
affected are the legs, in which probably from their depending situa-
tion, the vesications fill rapidly and break within  twenty-four hours
from their first appearnce.  Salmuth relates a case in which the in-
tumescence extended over the entire frame :\ but this is extremely
rare, excepting under the second or migratory  form,  in which it
trails over different parts  in succession, till the whole body has been
affected.
   In the erratic variety, the  complaint usually, and particularly in
adults, begins its attack in the face, and spreads in succession to the
extremities, the patch first formed healing as fresh ones appear be-
low.   Sometimes, however, other parts are seized first; and  per-
haps more frequently so when this variety shows itself in infants;
for here the parts about the navel are usually first affected, and the
disease winds downward to the sexual organs, which are often very
considerably tumefied and inflamed.  What, however, is usually de-
nominated the infantile erysipelas, is more commonly a variety of
gangrenous erythema, produced, in many instances, by want of clean-
liness, pure air, and nutritive  food.  The  inflammatory blush soon
assumes a livid hue, and is sometimes covered  with or  surrounded
by petecchiae :  the cuticle is separated to a considerable extent from
the cutis, breaks, and exposes a foul and ulcerating surface  that al-
most immediately passes into a state  of gangrene.   In some  instan-
ces, nevertheless, these cutaneous efflorescences are probably accom-
panied with a true erysipelatous fever: for in lying-in hospitals the
disease is said to have proved  occasionally contagious.
  The erysipelas  cedematodes, and e. gangranosum of Dr.  Willan,
appear to be misnamed, and consequently misplaced. They are more
accurately" erythemata, and have already been described under the
species erythema azdematosum, and e. gangrenosum.
  The usual causes are cold, intemperance, suppressed perspiration,
and the other common excitements of fever operating upon  an  ery-
thematic diathesis, and producing therefore  this peculiar  efflores-
cence in connection with  the  febrile attack.  In almost every in-
stance, there is evidently a  diminished vascular action ;  and hence
we meet with the  disease far most frequently in persons of delicate
habits, women, children, and those who have long resided in warm
climates.  In one instance it has occurred to me in a strong hearty
man, of plethoric form and sanguineous temperament,  well known
      * Principles of Surgery, i 239,
      t Consult. Med.-Chirurg,
      X Cent. i. Obs. 32.
VOL.  II.               52 
410
HiEMATICA.
[CL. HI.-OR. HI.
 to the  world as a public  character; but  in this case the diet had,
 from boyhood, been exclusively that of vegetables from an extraor-
 dinary disgust for '.nimal  food of all kinds.
   It is also said to have occurred in consequence of repelled gout,*
 suppressed menstruation,! and insolation, or exposure of the head to
 the  mid-day rays of the summer  sun.J  It may  possibly in some
 idiosyncrasies be produced by indigestible or rancid foods ; and es-
 pecially by shell-fishes which disagree with  the stomach ; though
 there is reason to believe that in many cases of this kind  erysipelas
 has been mistaken for urticaria, or roseola.
  From  this view of the subject the general mode of treatment may
 be expressed in a few  words.   Venesection was formerly recom-
 mended, and  has been so of late by a few writers, but upon mistaken
 principles.  I can conceive very few cases in  which it has a chance
 of being serviceable; and the application  of leeches always exaspe-
 rates the etflorescence.   We  should first  cool the  body  by  gentle
 laxatives, and instantly have  recourse  to a tonic plan.   The bark
 given largely, as long since  warmly and  judiciously recommended
 by Bromfield§ and Colly,|| has rarely failed of success.  Dr. Fordyce
 was in the habit of giving it,  in a dangerous state of the disease, in
 the proportion of a drachm of the powder every hour. He  tried it for
 twenty years  and with growing confidence.   Where, however, there
is much  evening or night  exacerbation, it  may temporarily be drop-
ped for some  warm  diaphoretic, as camphor, with small doses  of
James's powder, or the spirit or compound spirit of sulphuric ether,
in saline draughts made with the  carbonate  of ammonia.  If the
head be  much affected it should be  lightly covered with linen wet-
 ted constantly with vinegar and cold water, or equal parts of water
 and the solution of acetated ammonia:  and, if the vesications ooze,
they should be frequently dusted with finely powdered starch, or a
powder consisting of half starch and half calamine.   The diet should
be light  and of easy  digestion.  Opiates have rarely succeeded in
procuring sleep ; and have generally added  to the mental  irritation.
* Stoll, Rat. Med. v. p. 436.
t Alberti, Jurisprud. Med. in. 796.
X Pelargus, Med. Jahrgauge, v. 185.
i Medical Communications, n. 4.
|| Id. ii. 3. 
                   SANGUINEOUS FUNCTION.              4 1  I


                    GENUS  III?


                       EMPYESIS.

                  pustulous Epantftem.

ERUPTION OF PHLEGMONOUS PIMPLES ;  GRADUALLY  FILLING WITH  A  PU
  RULENT  FLUID ;   AND   TERMINATING  IN  THICK SCABS,  FREQUENTLY
  LEAVING PITS OR  SCARS.

Empyesis is a term  of Hippocrates, and is to be found in  the fifth
book  of his Aphorisms.  It  is derived from  the Greek eftiruou, or
ift-rvia, " suppuro."  The Greek writers also use,  and perhaps more
generally^ ecpyesis, from txvvov, of  similar meaning.  The same
distinction between the terms is made in the  present system  as be-
tween emphlysis and ecphlysis; the former being limited to signify
pustular eruptions produced  by internal and  febrile affection,  and
the latter to signify those that are merely cutaneous  or superficial,
or with which internal affection is not necessarily associated.
  The genus empyesis contains not more than  a single species that
has yet been discovered, and that is,

       EMPYESIS VARIOLA.           SMALL-POX.
                         SPECIES  I.

                EMPYESIS VARIOLA.

                        SsmnlUftot.

PUSTULES APPEARING FROM THE THIRD TO THE  FIFTH DAY ; SUPPURAT-
  ING FROM THE  EIGHTH  TO  THE  TENTH :  FEVER  A  CAUMA : CONTA-
  GIOUS.

When the small-pox first made its appearance in the world we know
not.   There is no substantial ground for believing that the disease
was known to the Greeks or Romans.  It has been thought, indeed,
by some persons, that the former have  glanced at it under the name
of anthrax;* but the idea is too wild  for serious  refutation.   It is
far better ascertained that it existed in Asia, and especially in Chi-
na, for an incalculable period  before it was known in Lurope ;  and
from the accounts of the Jesuits, to which  we  shall  have  to refer
Hahn, variolorum Antiquitates e Grtrcis erutse. 1734.
GE. III.] 
412                      H«MATICA.          [CL. ™-~°*' lU'

more particularly presently, it is  highly probable  that  the art of
inoculation was  practised throughout  the Chinese empire, oeiore
the natural contagion Had reached the European shores.  About tne
middle of the sixth century it is supposed to have been conveyed Iby
trading  vessels from India to Arabia; and there is no question that
the triumph of the Arabian  or  Saracenic arms introduced it  from
Africa into the Levant, Spain, and Sicily.              #    .
  The first accurate description we have of it is contained in the
Almanson of Rhazes, written about the end of the ninth or the be-
ginning of the tenth century; in which, however, he quotes  from
an Alexandrian physician of the name of Aaron, who  had written on
the same subject as early as the year 622.
  Yet it is very  singular, that neither Rhazes nor Aaron,  so tar as
their writings have reached us, make mention of the contagious
property of the disease, chiefly accounting for it as produced by an
ebullition of the  blood, and particularly incident to the age between
childhood and youth.  And  it is equally  singular that it should be
asserted by Aaron that the same person is liable to a return of it a
second or even a third time, proecipue cum sanguis sit acutus.   Has
the disease undergone any change since  this period so as  to render
those who have not had it  more susceptible  of its  influence, and
those who have  had it  less ?  In the  descriptive  part of the dis-
ease, little is to  be added to Rhazes'  statement, and, what is  more
singular, he recommends  the cool treatment.   Unfortunately,  how-
ever, the doctrine of concoction  and despumation of the  humoral
pathologists spread  afterwards so widely, and was so generally sup-
ported, as to  put to flight this correct and rational view of the sub-
ject ; and every  attempt was made,  by warm clothing and  the warm
bath, to maturate the peccant  matter and  drive it in as large a
quantity as possible to  the  surface ; by which the  slightest  cases
were violently exasperated, and too  often rendered fatal.
  The  severer  the disease, the sooner the  pustules show them-
selves,  thus completely reversing the law  of scarlet-fever;  a re-
mark for which  we were first indebted to the sagacious eye of Sy-
denham.  And hence in the confluent variety the eruption appears
on  the second or third day, while in the  distinct we have seldom
any traces of it till  the fourth, and often not till the fifth day.
  If a patient have accidentally become impregnated with the con-
tagion of the measles before inoculation or being exposed to  the
contagion of the small-pox, the  latter, as we have already  observed,
will, generally speaking, be retarded in its progress, and  not  make
its  appearance till the measles have  run through their course, upon
the common  law that the constitution is affected only with one dis-
ease at a time.   But to this common law we have already pointed
out various exceptions ; and as gout and rheumatism sometimes co-
exist, the  measles  and  small pox occasionally co-exist also.  In the
year 1769, Mr. King, of the Foundling Hospital, Dublin, inoculated
forty-three children of  the  establishment.   On  the  fourth or fifth
day afterwards, sixteen  of them sickened with the measles, and went 
 GE. III.-SP.  I.]       SANGUINEOUS FUNCTION.             413

 through the  disease regularly, yet the progress of the small-pox
 was not retarded or altered ;  for the pustules of the latter disease
 appeared as  those of the former  died away ; and  both complaints
 were of a mild character:  a like coincidence occurred in the ensu-
 ing year, and with a like favourable termination.*
   In this case the common law of retardation seems  to have  been
 interfered with by  some peculiar constitution of  the atmosphere ;
 for the effect was general to all who were under the influence of ru-
 beolous contagion.   In other cases we have a like interference with
 the common law of variola, from the idiosyncrasy of individuals or
 some temporary but equally occult power operating upon the  sys-
 tem.  There are some persons who seem to possess a natural immu-
 nity to its influence, and pass through life without ever being infect-
 ed, though  they may have  purposely  exposed themselves to the
^ most contaminated  atmosphere.   There are others, who, though in-
 capable of being affected at  one time,  lose  their  emancipation  at
 another. "  1 know an old nurse," says Dr. Huxham, " and one apo-
 thecary, who for many years attended persons, and a great number
 too, in the small-pox, and yet never had them ; nay, many that have
 industriously endeavoured  to catch this infection, by frequenting the
 chambers of the sick, have done it without effect;  and yet  some  of
 these  persons, some months or years after, have  been seized with
 the small-pox."t
    But not only does the susceptibility of the disease vary in degree
 at different times and in different persons, but the irritability  of the
 body beneath its influence.   Thus among fifty persons  who receive
 it at the same time and undergo the same regimen, we may perhaps
 have as many degrees of violence ; some dying beneath its severity,
 some escaping though with great peril, and indelibly seamed and
 scarred, and  others evincing little fever, and a very slight eruption.
 The present author caught it casually in London, when a child about
 six years old, and passed through it  with scarcely any disturbance,
 and not more than twenty scattered pustules.
   In like  manner  we  find,  under  inoculation,  that  while,  some
 persons throw forth a full crop, and suffer considerably from  fever,
 others  have  scarcely any febrile  symptoms,  and no more eruption
 than the pustule on the puncture ; the disease, in this case, exhibiting
 the same change as occurs  in inoculated  cow-pox, compared with
 the exanthem as received casually from the cow.
   It  was  at one  time doubted  whether this  slight  appearance
 afforded protection for the future.  There is now no longer any
 doubt  upon the  subject.  But we may go beyond this, and reasonably
 conjecture, that those who have passed through the  disease with but
 little inconvenience, are even less exposed to future  attacks than
 persons who have had it in.the confluent form, and whose faces are
 marked with its ravages.  For as the degree  of violence depends,

           *  Edin. Med. Comment. Vol. m. p. 443.
           '  Treatise on fevers, Small-pox, &'c. 
414
H/EMATICA.
[CL. IH.-OR. HI.
where there is no error in the treatment, upon the degree of irritabi-
lity, which the constitution manifests under the contagion, and as the
irritability and susceptibility march with an equal step,  he  is most
likely to have a renewal of the susceptibility in process of time, who
bears the  most  evident  marks of a greater susceptibility  antece-
dently.
  It has indeed been conceived by very distinguished pathologists
that the small-pox can never be had a second time, notwithstanding
various assertions in Support of this fact; and the argument is  thus
ingeniously put by Dr. Heberden, who  was himself a disbeliever:
" It  would be no extravagant assertion to say that here  in England
not above one among ten thousand patients is pretended to have had
it twice ;  and whenever it is pretended, it will  always be as likely
that the persons about the patient were  mistaken, and supposed that
to be small-pox which was an eruption of a  different nature, as that •
there was such an extraordinary  exception to what we  are sure is s
so general a  law.'**
  This remark is forcible, but  the actual occurrences are in many,
perhaps most of the instances appealed to, still more so.  For, from
the cause  I have just pointed out, those who have had a repetition
of small-pox, have generally, if I  mistake not, been able to exhibit
proofs  of  a prior attack in pits or scars on the face, or some other
part of the body, manifesting the  violence with which the disease
ran  its course, and  consequently  the strong predisposition of the
constitution towards it, and irritability under  its influence.   The
medical repositories are rich in cases of this kind, some  of them so
striking and so well established as to prohibit all doubt  whatever:
and in the two or three instances which it has fallen to my lot to
witness, 1  have traced the same  character;  for pits from the prior
attack  have been visible while the genuineness of the existing attack
was  in one instance substantiated by the test of inoculation.  That
erroneous statements upon this  subject have been very numerously
given  to  the world is unquestionable ; among  which we can find
little difficulty in placing that of Borrelli, containing the  history of a
woman who recovered from seven distinct attacks of small-pox, and
died on the eighth; the antecedent eruptions having doubtless been
those of some other exanthem or cutaneous efflorescence :  but the
clear and  incontrovertible cases  are sufficient to establish an occa-
sional departure  from the  general law, and teach us to look  without
a scoff upon the assertion of the oldest Arabian writers, and  particu-
larly the declaration of Aaron, that the disease occasionally occurred
a second,  and, in some instances  when there was a strong predis-
position to it, even a third time.
  A tike deviation from the ordinary path of procedure impresses
us in  the  history of  other  exanthems.  The  same general law
prevails very strikingly in measles and scarlet-fever, but we have
also a law of exceptions ; and the exceptions in  one disease seem to
* Medical Transactions, Vol. I. Art. xvn. 
 GE. HI.-SP. I.]       SANGUINEOUS  FUNCTION.              415

 hold a steady proportion to  those in another.  They are most fre-
 quent in scarlet-fever, fewer in measles, and still fewer in small-pox.
 In plague,  the general  immunity  lasts  but  for  a  few  weeks  ;
 yet some  who have  recovered seem  to be  protected for a much
 longer time, and several for life.  In influenza, it extends  through
 the whole duration of the existing epidemy, but the susceptibility
 recovers itself against the next visitation.   In some remittents, as
 yellow-fever, the patient continues little susceptible for many years,
 perhaps for the whole of his natural existence : in intermittents, the
 susceptibility, on the  contrary, is very  generally increased;  for the
 man who has  once  suffered from an  ague catches it again more
 readily than another.
   A high  degree  of fever is not  necessary to emancipate  the
 system in any exanthem ; and consequently not in small-pox.  It is
 upon this principle that inoculation takes its stand  in vaccinia as well
 as variola.   Febrile commotion, as we have observed already, though
 necessary to throw  the morbid poison to the surface, is necessary
 only in a small,  and  sometimes an almost imperceptible degree ;
 and if  it be  urged beyond this, the morbid poison will be increased
 in quantity,  the  ferment will acquire  a  wider  assimilation ;  and
 hence  the  fever and the  eruption  always  maintain  a balance.
 Provided the entire system submits to the influence of the contagion,
 the emancipation is always as perfect under a small product as under
 a large ; and itis wonderful to observe how completely this influence
 extends through every part of the system, often indeed without any
 disturbance  whatever, upon a deposit of the minutest  particle of
 variolous contagion  under the  cuticle;  for we are  perpetually
 witnessing cases,  or  rather  were, when variolous inoculation was
 more frequent, in which a full change has been operated on  the
 entire frame, though the only pustule has been that excited at  the
 puncture ; and the individual, before liable to the disease, is become
 liable  no longer.  And that  the blood  itself, and therefore every
 particle of the  blood, is  equally influenced in such circumstances,
 and even charged with the nature of the virus, is obvious from  the
 frequent communication of Jthe disease from  a  pregnant woman to
 the fetus; and this too  at times where the mother is no sufferer
 from the disease herself.
  A remarkable example of this last fact is given by Dr. Mead in the
 following words:  " A  woman who had formerly had the small-pox,
 and was near her reckoning,  nursed her husband who had caught it.
 At her full time she was delivered of a  dead child, whose body was
 covered over with pustules; a manifest sign that  it died of the
small-pox before it was brought into the world."*  Mauriceau has
another case  or two to the same effect :t and others have occurred
since, and are noticed in several journals of later date.
* De Variolis, Cap. iv.
:  Sur la Grossesse, et d'Accouchement des Femmes. Obs. 600. et 576. 
416
H KMATICA.
[CL. IH.-OK. HI.
  In these cases there is no assimilation or multiplication of morbid
leaven ; an influence is indubitably exercised, and that, too, over the
entire current of blood;  for it could not otherwise reach the fetus,
yet without any sensible effect on the mother.  What is the nature
of this influence ? is it by an infinitesimal division of the minute
drop  of contagion inserted into the skin,  or that received by the
breath ?  Whatever be  the way, it enables us to be less surprized at
the mode by which family taints,  as gout, scrophula, and  phthisis,
are transmitted from generation to generation.
  Unborn infants do not  always  receive the small-pox under the
same circumstances, nor in every instance even where the pregnant
mother  sickens with  the disease.   Sir George  Baker, who  was
indisposed to  credit these singularities, refers to two instances in
which the mothers having been inoculated had passed through the
eruption favourably, and  brought  forth infants  both  of whom three
years afterwards were  also inoculated with good effect.*  From all
which we collect, and  we can do more, that a like variation occurs
before birth, as we have just observed occurs  afterwards;  and that
different  individuals, or even the same individual under particular
circumstances, evince  a different degree  of susceptibility  ; so that
the contagion,  though  resisted at one time, is readily received at
another.
  There is another feature in the  physiology of small-pox, that is
peculiarly worthy of notice ;  and  that is the power which all deep-
seated organs possess of opposing a lodgement of the pustulous inflam-
mation on their own surfaces, and  driving it altogether externally
where it can do least mischief.  Dissections have abundantly shown that
the viscera and cavities of the interior  are never affected  with the
eruption, except such as,  like the  skin, are exposed to the approach
or ingress of air, as the nose, mouth,  trachea and its ramifications.
and the  entrance of the meatus auditorius.   As a general  rule,
pustules  are never found in  the  rectum, but  if there be  any pro-
lapse, and the  sphincter be exposed to the contact of air, that part
of the rectum, which  concurs in the exposure, will  share in the
common  fate of the external parts.
  To what extent variolous contagion is capable  of  radiating,  as it
issues into the atmosphere  from a diseased body, has  never  been
satisfactorily determined.  In laying  down the  general  rules of
febrile miasm, I ventured to state  that contagion or  miasm vene-
rated in the  living  body, does not appear to be very volatile in
any instance, and soon  dissolves in a pure atmosphere.   The conta-
gion of small-pox seems fully to  be governed by this  law.  When
small-pox was more frequent than at present, medical practitioners,
though passing casually from house to house, were rarely, if  ever,
accused,   of communicating  the  disease;  and Dr  Haygarth has
appealed to an evidence  of facts in proof that the sphere of vario-
lous contagion does not include a diameter of fifteen hundred feet,
and probably not a hundredth part of such a diameter.
* Med. Trans. Vol. n. Art. xix. 
OE. IH.-SP.  I.]       SANGUINEOUS  FUNCTION.             417
  As the susceptibility of small-pox  varies so considerably in dif-
ferent individuals, it is not to be wondered at that the irritability of
the system  to its influence should vary also, and consequently that
there should be  some difference in the period of time between the
supposed communication of the disease and its appearance by any
manifest tokens.  Upon the whole,  the interval may be calculated
to vary from six to twenty-one days in the natural small-pox ; and in
the inoculated, which anticipates the action a day or two, from four
days to eighteen.
  The writers of this disease  have subdivided it into an endless
multiplicity of forms: but the four following varieties are sufficient
to include the whole :

       x Discreta.                    Distinct  small-pox.
       C Confluens.                   Confluent small-pox.
       y Degener.                    Crystallized-pox.
                                     Horn-pox.
       3 Inserta.                     Inoculated small-p*ox.

   The pathognomic characters of the first variety or distinct  small-*
pox are the  following : Pustules  pea-sized;  distinct,  distended^
circular; the intervening spaces red; the fever ceasing when the
eruption is complete.
   The disease  opens  its battery with the usual signs of a febrile
cold fit, accompanied with vomiting, and  some degree of soreness
in  the throat.  About the fourth, sometimes on the  third day, the
eruption begins to appear on the face, neck and breast, in minute,
flea-bite spots, which  multiply  every night for the ensuing four
days, when there is  usually a pretty furl crop  of them over every
part of the body, though the face is,  in almost dll cases, far more
covered than any other part;  and that, according  to M. Camper in
the proportion of five to one.*   The head, face, hands and wherever
else the pimples show themselves gradually swell, and the eye-lids
are often so much distended as to close the eyes and produce blind-
ness ; the spaces between the pimples are reddish, and continue to
grow redder as the pimples become pustules and maturate ; the fever
is of the caumatic or  inflammatory kind, and  the  suppuration is
complete on the  eighth  day or thereabouts.   On the eleventh, the
inflammation and pustules manifestly abate, and the latter, measuring
the  diameter  of a pea,  dry away by degrees and scale off, and
wholly disappear on the  fourteenth  or fifteenth day,  with the
exception of those on the extremities, which, as they came out later,
commonly  continue a short time longer.
  Such is the ordinary course :  but the symptoms vary greatly in
severity, according to the degree of fever, and extent of the erup-
tion, which, as  already  observed,  hold a pretty accurate balance.
Where  the pimples  are  few and scattered there  is but  very little
indisposition; but where they are very numerous, though still dis-
  * Les Avantages de llnoculation, Sic. Paris, 1782.
it                   53 
418
H^MATICA.
[CL. HI.-OR. HI-
tinct, the  soreness, swelling and febrile heat are very distressm
and under this form the progress of the disease has often  been divi-
ded into four stages,  an incursive, an  eruptive, a maturating, and a
declining or scabbing, at each of which it discovers an exacerbation
of pyrectic svmptoms.  And when  the patient is an  infant, it is at
these times, and  especially on the  incursion of the disease,  occa-
sionally attacked with a convulsion fit, or perhaps several in succes-
sion, which it was once the custom to  make much  lighter ot than
the occasion justifies.
  The grand principle in  the treatment of small-pox, as ot all the
other exanthems that have past before us, is to moderate, and keep
under the fever; and, however  the plans that have been  most cele-
brated for their success  may have varied in particular points, they
have uniformly made this principle their pole-star; and have con-
sisted in different modifications  of fresh air, cold  water, acid liquors
and purgative medicines :  heat, cordials, and other  stimulants hav-
ing been  abundantly proved to  be the most effectual means of ex-
asperating  the disease, and endangering life.
  Dr. Mead seems to have been almost indifferent as  to the kind of
purgative employed, and certainly gave no preference to mercurial
preparations.  His idea was that all were  equally  beneficial that
would tend to lower  the system : " Indicium," says he, " certe satis
manifestum, quamcunque materiae diminutionem, fomitem igni sub-
trahendo, huic morbo apprime convenire."  And in this manner he
accounts  for the  mildness of the disease after any great evacuation, .
natural or  artificial; after acute diseases, immoderate  catamenia,
child-birth, and salivation.
  Mercury, however, appears to have a specific influence upon the
action of variolous matter; perhaps, as in the case of syphilis, upon
the quality of the matter itself: for though, when considerably dilut-
ed with water, it is  still capable of propagating the disease by in-
oculation,  yet Von Wensel  has shown satisfactorily that  when tri-
turated with calomel it  loses its energy, and in inoculation becomes
inert  and  useless.  Mercury has hence been  denominated in Ger-
many, remedium pancreston, and has certainly supported its charac-
ter as the best  corrector of the small-pox  we are  acquainted with
from  a period antecedent to the introduction of inoculation into Eu-
rope, to the present day.   " Physicians who attend  hospitals," says
Sir George Baker, " have frequently observed the  small-pox to be
particularly mild in  those  patients  who have happened  to  receive
the infection soon after a mercurial  phyalism; and inoculation is
said to have  been a  much  more successful practice in some of  our
American colonies since the use of calomel has been there introduc-
ed into the preparative regimen."  When given merely as a pur-
gative it is usually mixed  with  the powder or resin of jalap, and in
this manner acts much more briskly.
   Exposure to fresh and cold air is nearly, if not altogether, of as
much service as calomel;  and  hence the  patient, however inactive
and dejected he may be, should be roused from his bed, and  urged 
GE. IH.-SP. I.]        SANGUINEOUS FUNCTION.               419

to use gentle exercise either abroad or in a  cool capacious room.
Cold water is usually prescribed in large draughts for the same pur-
pose, and very generally proves highly refreshing.   The acids, and
especially the  diluted mineral acids,  have  a  peculiar  influence in
diminishing the extent of the eruption  ; insomuch that some inocula-
tors have been bold enough to prophecy the number of pustules a
patient would produce under a given quantity of the acid.   Wheth-
er any one of the acids has an intrinsic power beyond  the rest has
never been sufficiently  put to the test of inquiry;  nor is it clearly
ascertained in  what way  they operate towards  the  present effect.
They are an  excellent refrigerant in fevers of all kinds, but in
small-pox there  seems to be  a something beyond  this power,  and
they probably restrain the process of assimilation.
   Lemonade may conveniently form the common drink during the
fever; or a solution of cream of tartar in water,  which, as  tending
to  keep the bowels  gently  open, will  be  preferable.   When  the
fever is considerable, the  purgative should be repeated at  each of
its exacerbating stages; and if convulsion-fits arise, the spasmodic
irritation is best removed by laudanum.
   The  pathognomic characters of the confluent variety are  the
 following :—Pustules confluent, flaccid, irregularly circumscribed :
 the intervening spaces pale : with great debility.
   In this variety the eruption assumes, at first, the  appearance of a
 general efflorescence without any distinctive points; innumerable
 pimples, however, show themselves  about  the  third day, being a
day or two sooner than in the discrete variety.  They soon coalesce
from their thronging number, and become filled, not with pus, but a
yellowish serum, for this variety seldom suppufates regularly.   The
fever is  violent and exhibits a synochous or typhous type ; and, in-
stead of subsiding on the appearance of the eruption, as in the dis-
tinct variety, very  generally increases. The  head is oppressed,
the eyes inflamed, the brain comatose or delirious.  After the eighth
day  the  detached pellicle, covering a large  secretion  of this
virulent  fluid, becomes brown, and not yellow as in the  distinct sort.
Peculiar to  the  confluent small-pox  is salivation  in adults,  and a
looseness in children ; the former always attends ; the latter more
rarely.   The spitting begins as soon  as the eruption  appears or
within a day or two afterwards: the saliva is at first thin, and easily
and  plentifully discharged ;  but, towards the eleventh day,  which is
the period of the greatest danger,  it becomes viscid and is discharg-
ed with  great difficulty;  the looseness  in children, however, con-
tinues beyond this period.
   When the disease terminates favourably,  the swelling of the face
about this time  begins to  abate, and  that of  the extremities com-
mences.   But, if the. constitution be incapable of counteracting the
weakness under which it is suffering,  or the mass of disease  with
which it is oppressed, and particularly the exacerbating or seconda-
ry fever, as  it is called,  which takes  place at the stage of matura-
tion, the cuticle  suddenly becomes  flattened, the features sink, tho 
420                     H/l.MA l tCA.           [CL. IH.-OR. III.

pustules  are  depressed; the coma increases,  flea-bite  spots  are
sprinkled over the body, succeeded  often by hemorrhages from dis-
solved blood; the pulse flutters and the patient expires; usually, as
already observed, about the eleventh, but sometimes not  till the
sixteenth day.
  In the  commencement of this variety, the same reducent plan is
to be  pur-ued, as already  recommended in the preceding variety  ;
and the effusion of cold water may be added  to a free use of fresh
and even cold air.  Bleeding is  a doubtful remedy, and its  propriety
must  entirely depend upon the  constitution or habit of the indivi-
dual,  and the nature  of the prevailing epidemy.  In a state of high
entonic health, and  firm elastic fibre, it may be  allowed, and per-
haps  repeatedly: but  we should always  bear in mind,  first,  that
the plenitude of the disease does  not so  much  depend  upon the
strength  or weakness of the frame, as upon i s  susceptibility of the
contagion, and irritability beneath its  action :  and next, that in con-
fluent small-pox  the process  of maturation does  not take place kind-
ly or  perfectly,  and  that the fever, often a synochus, has always a
tendency to run  into a  typhus,  particularly when  the temperament
of the atmosphere predisposes to this  type.  On this account, it will
often  be  found necessary, and particularly towards the stage of ma-
turation, to  support  the tone of the system instead  of reducing it.
Camphor offers us one of the medicines for this purpose ; and may
be given in solution or in the form of  pills.  The  latter is generally
the most convenient, as it can  thus be taken in  a larger quantity,
and needs not interfere with volatile neutrals,  etherial compounds,
the acidulated decoction of  cinchona, or  the same tonic  in a more
powerful form.  If, indeed, on  the accession of the secondary fever,
the pulse should suddenly sink, the pustules flatten, and the surface
turn pallid or purple,  wine must be  added to  the other  remedies,
blisters or sinapisms applied to  the feet or legs;  and opium be ad-
ministered if a diarrhoea should supervene:  though in the earlier
stages of the disease this last symptom should be very cautiously in-
terfered  with.   Some part of the secondary fever may probably be
set down to the  score of the absorbed virus, now  thrown back upon
the blood from every part of the surface ; and to  disarm this source
of  exacerbation, it may be convenient to  open the pustules as they
ripen, and let  them  discharge  their  contents  externally.  And to
save  the face as much  as possible from those  exulcerations of the
true skin that terminate in pits and  scars, a mask of fine linen or
cambric should be worn over  it, illined with cetaceous cerate to
soften the integument and defend it from the air.
   Small-pox, then, may well be contemplated as a  fearful disease.
It is so at all times from the uncertainty of its prognosis; but espe-
cially when it assumes  a severe character.  And  it is so, moreover,
not merely on account of its own ravages, but of the tendency it pro-
duces to subsequent  evils,  after its  own course has  subsided.   In
many cases  the constitution is incapable of  recovering from the
general  disturbance  and debility it has, introduced, and hence atro* 
GE. HI.-SP. I.]
SANGUINEOUS FUNCTION.
421
 phy,  dropsy and hectic are by no means uncommon results.   But it
 more frequently proves  mischievous by stirring up some  heredita-
 ry taint that might otherwise lie quiet through life; and in this way
 becomes an exciting cause of scrophula, consumption, and  gout.
  The horn or crystalline-pock, it is  only necessary to notice, as
 forming a somewhat singular departure from the usual course of the
 disease, though not often accompanied with danger, or  distinguish-
 ed  by an  overloading eruption.  Its pathognomic characters are
 set down in the Nosological Synopsis as  follows :  Pimples  imper-
 fectly suppurating; ichorous or horny; and semi-transparent.
  From some unknown cause, the variolous fluid is, in this variety,
 secreted and thrown upon the surface in the form of lymph, and is
 never exchanged for that of pus.  As the finer part of the fluid is
 absorbed it loses  its pellucidity, and the vesicular  pimples  appear
 whitish, and preserve this  hue  till they dry and  peel off.  This is
 particularly the  case  in  persons of a fair and  delicate skin, but,
 where the skin is darker or coarser, they become brown, hard and
 horny:  and hence it is always in this  way that the present variety
 terminates amongst negroes.  Whenever  small-pox occurs a second
 time, it usually shows a  tendency to this modification.
  The fourth variety under which small-pox is to be found  is the
 artificial modification known by the name of inoculation  : a most im-
 portant advantage to mankind before they  were acquainted with the
 equal or nearly equal protection afforded by the virus of cow-pox.
   Its peculiar characters are thus described in the volume of Noso-
 logy  : Orange-coloured  aveola  about the puncture ; pain  in the
 axilla about the seventh  day : disease mostly mild ; and the purulent
 discharge sometimes confined to the punctured parts.
  This  mode ,of communicating the disease, like the natural disease
Itself, appears to have  reached Europe from the east, and especial-
 ly from  China, where, according to the statements of the Jesuits,*
it has been practised immemorially by perhaps the simplest and best
means of communication  that  has hitherto been devised,  that of a
needle charged with the  contagious matter of  a pustule, and intro-
duced transversely under the cuticle.  From  China the  discovery
appears to have travelled  into India, and thence to Asia Minor.  Its first
employment in our own  country seems to   have been the result of
some  fortunate observation, made, like that of cow-pox  inoculation,
in the rudest parts of  it; for the practice of " buying" the  small-
pox, which was in fact a  communication of the  disease by  insertion,
was prevalent in Wales at a very early period,  and appears to have
been  also occasionally resorted to in the Highlands of Scotland, from
an antiquity nearly as  remote ; of which abundant proofs are to  be
found in  various articles  in  the  Philosophical  Transactions.!  All
such  practice, however, and  even the knoweldge  of it,  seems to
*Lettres Edifiantes et Curieuses, &c. passim.
 See Vol. xxxii, years 1722-3, and especially Dr. Williams's account, 
422
HjEMATICA.
[CL. 1II.-OR. III.
 have been confined to the remote  quarters in which it accidentally
 arose, as  late  as the year 1721, when  Lady  Mary  Montague who
 had witnessed its success in Turkey, and had had a son successfully
 inoculated there, submitted an infant daughter  to the same process
 at this  time in London.  Yet  so little  acquainted with  its success
 were the  public, and even the  medical profession,  at this period,
 and so cautious  in giving it credit, that an experiment of Its effect
 was ordered to be made in the same year on  six condemned crimi-
 nals, allot*whom were  fortunate enough to  recover, and who thus
 redeemed their lives.  This gave countenance to further attempts;
 yet the innovation, like that of inoculation from cow-pox, was sharp-
 ly and pertinaciously opposed, and not more than seven hundred and
 sixty-four persons, according to Dr. Jurin's calculation, were inocu-
 lated all over  England from 1722 to 1727.
  Unfortunately the practice of treating the diseaae with cordial*
 and a hot regimen at this time prevailed, and was too generally ap-
plied to the inoculated as well as to the natural process, by means
of which the former was often rendered a severe and in many cases a
fatal disease; though it was impossible for the dullest intellect to be
altogether insensible to its high comparative advantages.  By de-
grees,  however, the  refrigerant and reducing plan  obtained a tri-
umph, and the triumph  of inoculation was a synchronous step.  Yet
half a century afterwards the exploded  plan was still persevered in
by some practitioners, and it is instructive to mark the comparative
mischief that still accompanied it.   " I found," says  Sir George Ba-
ker, writing in 1771, "  that in the counties  of Essex,  Norfolk, and
 Suffolk many thousands of people, of all ages and constitutions, and
some of them, of every apparent disadvantage, bad been inoculated
with  general  good success; whereas at Blandford, in  Dorsetshire,
 out of three hundred and eighty-four, who were inoculated, thirteen
 actually died, and many others  narrowly escaped with their lives
from the confluent small-pox."*  This gives us a direct mortality of
 something more than  one in thirty; and it is almost needless to add,
 that in the successful districts here  alluded to, the cooling plan was
 prevalent, and at Blandford that  of hot beds and a warm regimen.
  Even this result, however, with all its fatality offers a wonderful
 improvement upon the  march of natural small-pox ; in which one
 out of every three or four have  been computed to die among adults,
 and one out of every seven among infants ; while, wherever the cool-
ing and reducent plan has  co-operated with  inoculation, the casual-
 ties are not more than one in five  or six hundred.
  Yet great as is the intrinsic advantage of inoculation even upon
 its lowest scale, there is one evil which has  always accompanied it,
 and which, in a nation so justly  proud of its civil liberties as Great
 Britain,  it is almost impossible to provide  against;  and  that  is
 the  wider diffusion of variolous contagion through the atmosphere

  * Med. Trans. Vol. n.  Art. xix. Compare M, Gatti's JN'ouvelles Reflexious suv
 la Practique de l'lnoculation.  Paris 1770. 
GE. IlI.-SP. I.]
SANGUINEOUS FUNCTION.
423
by the indiscriminate use of inoculation  in all places.  And hence
it has been very forcibly observed in our own  day by  those  who
have  written  most warmly in favour of vaccination, that small-
pox inoculation is upon this ground a greater public evil than good;
since the multitude who will not consent to be inoculated, receiving
the natural disease  more generally than they  otherwise  would do,
the total mortality is greater  than before inoculation  was  had re-
course to. I was at first induced to think that this statement was a little
too highly  coloured for a particular and  present purpose.   But on
turning to  Baron Dimsdale's  tables of calculation drawn  up nearly
fifty years  ago,  I  find him arriving at the very same conclusion ;
and we fairly affirm, that the deaths from small-pox, since the intro-
duction of  inoculation, have increased in consequence of  the more
extensive diffusion of variolous contagion in the proportion ot four-
teen or fifteen upon every  hundred.  The bills of mortality indeed
give us something more than this.
   By what means  variolous contagion received by a puncture be-
comes so much  milder than when received  from the  atmosphere is
a problem  that has never been satisfactorily solved.  Something is
unquestionably  due to the  preparatory progress of purgatives and a
 reducent regimen; but, as the same mildness of character does not
 obtain in  the natural disease, where the same preparation  has been
 submitted  to  antecedently, some  other power must be sought  for.
 Under inoculation, and with the  usual precautions, the  eruption is
 commonly distinct and widely scattered; yet the most striking cha-
 racter in the  inoculated form is that  when the eruption  is full, and
 even confluent, the secondary fever, so alarming in the natural dis-
 ease, is here for the most part slight, and sometimes  altogether ab-
sent.  This exacerbation is usually  ascribed to an absorption of the
contagion  from  the pustules; but the feature before us shows that
there  must be a something distinct from absorption, though perhaps
acting in union with it.  Is the virus from the first less irritant, and
less capable of exciting much secondary fever,  for the very reason
that it was less  capable of exciting much primary ?
   It is on  this account that variolous inoculation may be  submitted
to, without danger, by  feeble infancy,  advanced age, and even ca-
chectic  habits  in  every stage of life; and that  the season of the
year does  not seem to be  a matter of great importance.   Pregnant
 women, however, ought  never  to  be exposed  to  it, nor infants,
 where there is  a choice, till after the irritation of teething.
   The operation is perfectly simple; the needle originally employ
 ed in the  East is as good an  instrument, as  any,  though the lancet
 is preferred in general.  It is only  necessary to deposit a minute
 drop of the contagion under the cuticle, or at least to make such a
 wound as  may give forth a single drop of blood.  It  is preferable to
 take the fluid before the pustule suppurates;  as afterwards it seems
 to partake of the nature of common pus as well, and  produces a lar-
 ger circle of inflammation, and on this account also it cannot so fully
 be relied  on.   The puncture does not so completely disappear as in 
424
H.EMATICA.
[CL. III-OR. III.
 that with vaccine  fluid, but it is often scarcely visible for three or
 four days.   At this period, a  minute papula may be traced, a little
 itching is felt, and sometimes there  is a slight inflammation.   On
 the sixth day, a pain and weight are  felt in the axilla, proving that
 the lymphatics of the arm have  become affected, and that the virus
 is conveyed  into the system.  On the seventh  or eighth  day,  the
 precursive symptoms of transient shiverings,  head-ache,  and  pain
 in the back  are perceived, and  immediately followed by the erup-
 tion itself;  though  in this mild form of the disease the only erup-
 tion, as in, the inoculated vaccinia, is the  pustule on the puncture or
 a few  which directly  surround  it.    Where the disease spends  it-
 self in this manner the local efflorescence commonly spreads over a
 larger area than otherwise, and  the adjoining lymphatics participat-
 ing  in the irritation, the tenderness and sense of weight are increas-
 ed in the axilla.   Where the symptoms are unfavourable there is a
 purplish, instead of a rosy inflammation, or a narrow, deep red, cir-
 cle  surrounding the  puncture, with  a dip or depression in the pus-
 tule.
  The treatment is to be the same as that already pointed out for the
natural disease :  but it should vary with habit,  constitution, or age
of the individual.  Sufficient attention was not always given to this
remark formerly: for the  preparatory regimen was a bed of Pro-
crUstis  to  which every one was alike compelled to  adapt himself.
Sir  George  Baker openly complained of this inconsistency in  his
own day;* but it was very generally continued  notwithstanding his
censure.
                      GENUS  IV.

                       ANTHRACIA.

                  CJarfmncttlar Sfatttiicm-

ERUPTION OF TUMOURS IMPERFECTLY SUPPURATING WITH INDURATED EDGES.
        AND, FOR THE MOST PART, A SORDID AND SANIOUS CORE.

The present genus, denominated anthracia, from xtftx%,  "  a burn-
ing coal," by its definition embraces two diseases of very different
specific characters, though closely  according in  their generic marks.
j. ijcsg Eire*

            1. ANTHRACIA pestis,             plague.
            2.---------RUBULA,              YAWS.
  There have been, however, and still continue to be, great disputes
* Med. Trans. Vol. h. p. 2P2. 
GE. IV.]
SANGUINEOUS FUNCTION.
425
among the nosologists, as to the proper station of both these species;
many contending that plague ought not to be regarded as an exan-
them, and most writers having hitherto  contemplated yaws as an
impetigo, or some other dysthetic affection. Dr. Cullen has expres-
sed a doubt whether the first should not be removed from the order
of exanthems into that of fevers ; Vogel has actually introduced it
into this last  order; Willan  has  rejected it from the exanthems.
Parr arranges it as an exanthem, in his article Nosology, having pre-
viously,  like Willan, rejected it  from that  division  in his  article
Cutanei Morbi.  In his  remarks subjoined to the article Nosology,
he  again acknowledges that " on reflexion it appears improper" to
introduce it into the list of exanthems ;  and in his article Pestis,
he  asserts more roundly that  " there is no foundation  for arranging
plague amongst the exanthemata ;  and that it should be reduced to
the asthenic remittents.  Sauvages, Linneus, Sagar, and Macbride
have entered it in the order in which we have placed it in the pre-
sent system.
   In few words, there  appears strong and almost incontrovertible
reason for thus placing it.  The fever, as will presently be  shown,
is eruptive, and as specifically so as that of any of the exanthems;
it is contagious like most of them ; and, although frequently occurring
oftener than once in a man's  life,  we have the concurrent testimony
of all the writers, who have been eye-witnesses of its effects, that  it
renders every one less  susceptible  for a certain period afterwards,
and some for the whole term of their existence.
   With respect to yaws, the diversity of opinion has been  quite as
considerable as that respecting plague.  Generally speaking, it has
been placed in  the loose and indeterminate class which has been dis-
tinguished by the name of cachexies; Sauvages and Sagar arrange it
in  the order tubera  of this class;  Cullen in  that  of impetigines.
These writers take little or no notice  of any  kind of febrile features
that accompany it whether  specific  or  sympathetic.  Dr. Young
pays as little attention to the  febrile symptoms by which it is said to
be  distinguished, and at the same time transfers it from the division
of cachexies (cacochymioe as he denominates them) to the order  of
paramorphiae  or  structural  diseases.  Dr. Winterbottom,  and Dr.
Dancer,  on  the contrary, contend that a slight fever is  its primary
symptom; and  Dr.  Ludford,  to whom  we  are  indebted  for, per-
haps, the best history which has yet been given of this disease, de-
scribes it as a proper eruptive fever,  totally unconnected with diet,
lues, or any other taint in the blood ;  commencing with alternations
of shivering and heat, lassitude, want of  appetite, and pains in the
head and loins  to so  great a degree as to prevent sleep; the  fever
and every inconvenience diminishing after the eruption, and the ap-
petite returning.   So that, like small-pox, it appears to have a re.
gular accession, height and decline; and, as already observed, may
be propagated by inoculation; and is never known to occur a second
time.  Hence Parr, who seems to have long wavered in his opinion
concerning the real nature of this disease, regarding it at one time
  vol. n»                     64 
426
HjEMATICA.
[CL. IH.-OR. Ill,
as a pustulous exdnthem, and afterwards^ as a mere cuticular intumes-
cence, returned, at last, with a decided mind to his first opinion, and
again asserts that " the detail  of symptoms shows that the disease is
truly exanlhematous."
  This view  of the subject  will therefore abundantly justify the
present arrangement of  both  these  diseases ; support their preten-
sions to the character of carbuncular exanthems; and consequently
develope the nature of the connection of yaws with plague, under a
nosological method founded on the principle of symptoms.   In their
individual or specific characters they are indeed highly discrepant,
but this is not sufficient to call for a separation, while they agree in
the  common  outline that may form  the basis of a generic division.
The tall and stately acacia of Egypt and the delicate sensitive plant
of our own green-houses belong to  the same genus in botany, how-
ever inaccordant they may appear to the eye  of an ordinary spec-
tator.
                         SPECIES  I.

                 ANTHRACIA  PESTIS.

                           Plague.

TUMOURS BUBONOUS, CARBUNCULAR  OR BOTH; APPEARING  AT AN UNCER-
  TAIN TIME OF THE  DISEASE : FEVER A  MALIGNANT TYPHUS, WITH EX-
  TREME INTERNAL HEAT AND DEBILITY : CONTAGIOUS*

It is happy for us, that, in describing this dreadful scourge, we are
under the necessity of referring to foreign countries,  or to remote
periods in the history of our own, before the  great  advantage of
public cleanliness and ventilation in our streets was sufficiently at-
tended to or even known.  The earliest visitation of the plague that
occurs in English history was in the year 430;  the last time it ap-
peared as an epidemic was in 1665, and the last notice of it in the
bills of mortality was in  1679.   In Edinburgh  it has  not prevailed
since 1615.
  From the diversified and clashing accounts that are  given of this
disease by different writers and  eye-witnesses in different  ages, or
different parts of the  world, we are justified in laying down the three
following varieties;  which, while they offer the  chief points  of dis-
crepancy, will be found in their  explanation to  reconcile the seem-
ing discordancies  of  established authorities.

x Fructifera.                The disease extending  to about the
  Common plague.           fourteenth day ; and relieved by the
                             appearance of the eruption. 
•E. IV.-SP. I-]      SANGUINEOUS  FUNCTION.              427

5 Infructifera.              The eruption imperfect or suppressed ;
  Uneruptive plague.         transferred to some internal organ;
                             or superseded externally by stigmata
                             and vi bices.
y Erythematica.            The body covered over with trails  oi
  Erythematous plague.      vesicular erythema, producing deep,
     J                        sanious, and  gangrenous ulcerations
                             as it spreads, often to the loss of one
                             or more limbs.

  The whole of these varieties have  sometimes been exhibited  in
 the same epidemic ; the last, however, is the least frequent, wheth-
 er alone or in conjunction with the rest.  All  of them appear  to
 have been present and intermixed in the Aleppo plague of lbbO-W,
 so clearly and strikingly described by Dr. Patrick Russell, physician
 at the time to the British Factory  established  at  that city, tor  he
 speaks of the pestilential eruptions appearing  under the form ot bu-
 boes, carbuncles, or other exanthemata :  among which last he takes
 particular notice of an  erysipelatous  redness  forming streaks of a
 reddish  purple or livid colour, intermixed with vibices and wheals,
 or large blue and purple spots, the maculae magnae of authors; while,
 in some cases, he observes that an extraordinary concurrence of these
 eruptions took place, which, however, was chiefly remarked among
 children under ten years of age.
   In the Barbary plague of 1799 and  1800, so fully  and excellently
 desoribed by Mr. Jackson,* who was an eye-witness  to its effects,—
 the  first and second of  the  two varieties here  offered, the  fructife-
 rous and infructiferous, were intermixed, while the erythematic
 seems to have been absent.  It was probably absent also in the plague
 of Moscow of the  year 1771, as it is not  [noticed by Dr. Mertens,
 who gives a full description of both the other  modifications.  In the
 London plague of 1665, all  of them seem to have occurred occasion-
 ally ; the first and the  second, however,  most frequently, examples
 of which are to be found in Hodges, Sydenham, Sir Gideon Harvey,t
 and  indeed all the writers; while, in allusion  to the last, Sydenham
 compares the inflammation of the  plague, as  it often appeared, to
 that of an ignis sacer,'by which he means an  erysipelas;  in which,
 nature, he tells us, expels the matter of the disease from the blood
 to slightly elevated tumours dispersed over the surface in broad red
 patches: only that this ignis, says he, is more violent than the ignis,
 sacer ;t—" ignis noster isto sacro longS  divinior est."
   In the plague of Athens,  on the contrary, as described by Thucy-
 dides and Lucretius, we are not sure of  the existence of buboes, as
 not  being distinctly noticed, though probably included  in the inflam-
 mations that are stated  to have fallen upon the privities  (t* «<&»«,)

           *■ Account of the Empire of Morocco, &c. 4to. 1809.
           t City Remembrancer, passim.
           X Febris Pestilens, et Pestis Opp. Sec.  u. Class n, 
428                     HJSM^TICA.           [cl. iii.-or. hi.

while the last two varieties were perpetually intermixed; the chief
eruption, however, being that of %he vesicular erythema, the sacer
ignis, or holy fire, as observed by  Sydenham.   In  consequence of
which, Thucydides tells us, that « the surface of the body was nei-
ther violently hot, nor wan;  but reddish, livid, and covered  over
with an efflorescence of minute  vesicles  and ulcers,"—^xvxrxtvxif
fitx^xti xxt tXxtrti:—but that the interior parts were so burning that
the sick could not endure the lightest covering or clothes, and ea-
gerly threw themselves into cold water.   And he adds,  that the dis-
ease, in its ulcerative progress, commencing in  the head or the up-
per parts of the  body, migrated over the entire frame, and  often
fixed itself permanently on the sexual organs, the hands, or the feet.*
The whole  of which course is by Lucretius  described under the
express name of sacer ignis, or holy fire.

          Et simul, ulceribus quasi inustis, omne rubore
          Corpus, ut est, per membra sacer quoin diditur lGNiS.t

  The entire  passage precisely corresponds with the  character of
the erysipelas pestilens of Lorrain, delineated  under this  name  by
Sauvages, who has copied freely both  from Sydenham and  Hoff-
man ;  but which,  though he calls it an erysipelas, had, as he admits,
the closest affinity with plague  in its  most  malignant  form, " cum
atrocissimo morbo pestilenti summam affinitatem habet;" and which
was in reality this disease in the form before us.  u Each," says he,
" commences with horror, burning heat,  delirium, prostration of
strength, vehement pain of the back and head ;  in each the burning
matter of the disease breaks forth on the fourth day on the axillary
or inguinal glands, and spreads to the  feet in the form of the  ignis
sacer: in the glands it produces abscesses;  in  the extremities, gan-
grene."  It is the mal des ardens of the French writers ; and,  in its
malignant variety, the erysipelas gangrenosum of Willan.   Much of
this difference, however, seems to be. dependent upon local or acci-
dental circumstances, and especially upon the state or constitution of
the atmosphere.  Thus we are told by Sir James M'Grigor, that
when the disease first broke out in the Indian army in the course of
its laborious expedition to Egypt, the  cases sent from the  crowded
hospitals of the 61st and 88th regiments were, from the commence-
ment, attended with typhous symptoms : while  those from the Ben-
gal volunteer  battalion  and  the other corps encamped  near the
marshes of El-Hamed, evinced uniformly an intermittent or remit-
tent type ; and those that occurred in the cold and rainy months of
December and January,  an inflammatory character; after which, as
the weather became warmer, the disease at Cairo, Ghiza, Boulac,
and the isthmus of Suez, wore the form of  a mild continued fever.t
* Hist. Lib. ii. 50.
t De Rer. Nat. vi. 1164.
J. Medical Sketches of the Expedition, &c. 
OE. IV.-SP. I.]         SANGUINEOUS  FUNCTION.           429

  The plague of London  in 1665 was, in like manner, distinguish-
ed by a peculiar constitution of the  atmosphere, which  excited  an
epidemic  synochus of great  violence and  danger,  often accompa-
nied with  symptoms or rheumatism  or pleurisy, and which seems to
have added considerably to the progress and mortality of the plague.
Sydenham expressly calls  it a pestilential fever, febris pestilentialis;
and adds,  that the  fever of the plague, after it  had  broken out, so
completely assimilated itself  to its character, that in the second or
infructiferous variety it was  extremely  difficult  to distinguish be-
tween the one and the other.*
  In like  manner Thucydides expressly tells us that whatever inci-
dental complaint any person  was labouring under during the plague
at Athens, it was sure to run  into this disease, which swallowed up
every other.  Yet, he adds that at  the commencement of the plague
complaints of all kinds were  peculiarly uncommon; insomuch  that
by  the acknowledgment of every one the year  seemed  to  have en-
joyed a general immunity.f
  The plague at London  first attracted attention  about Midsummer,
and augmented in its destructive ravage till the  autumnal equinox,
at which  time about eight thousand died within the bills of mortal-
ity in the space of a week,  though two thirds of the inhabitants at
least had fled into the  country to avoid infection.   From this time it
suddenly  put on a milder  character and made fewer attacks, nearly
ceased with the cold  of the winter,  and totally vanished  in  the
spring: the  epidemic fever, nevertheless, remained for a twelve-
month longer, though  this,  also,  was both  less common and less
virulent.
   The same controlling circumstances take place  all over the world;
and in studying the history and progress of the disease we must al-
low for the changes they effect.   Dr. Mertens has well described this
progress  in  the plague of Moscow of 1771,  at which time he  pre-
sided over one of the largest hospitals of the imperial capital, and
was an eye witness  to its ravages.^  Having noticed its liability to
modifications from the above causes, he tells  us, that in general it
begins with  head-ache,  giddiness,  horripilation,  prostration   of
strength, fever, nausea, vomiting,  redness  of  the  eyes, a dejected
countenance, and a white foul tongue.  A  tickling  attended  with
slight pains, is perc-ived in  the parts  where the buboes and carbun-
cles afterwards break  out.  " The former," says he, " are glandular
swellings, not acutely  painful, and  more or less elevated;  usually
seated in the groins or arm-pits, but  occasionally occurring in the
neck, cheeks, and other organs  of the  body."  The latter he  de-
scribes very nearly in the words already employed in the specific
definition of the carbuncle or anthrax in the preceding pages of this
  * Sect. n. Cap. i.
  t Hist. Lib. u. 49.
  X Observationcs Medics de Febribus putridis, de Peste, nonnullisque alijs mor*
bis. Vindebon.  1778. 
430
HjEMATICA.
[CL. IH.-OR. IH.
 work, though he observes, that " in the plague this tumour evinces
 somewhat less prominence, pain, and  inflammation, than when it
 arises as an idiopathic affection."
   ""Many," he tells us, " died on the first or second day  of the at-
 tack, before either of these kinds  of tumors made their appear-
 ance." In such cases, an eruption of petecchia?, macula; or vibices,
 like what occur in putrid fevers, usually took place a few hours be-
 fore death; but  sometimes the disease was so sudden as  to outstrip
 the march of these active precursors of dissolution.  Almost all who
 died were cut off on or before the  sixth  day : insomuch  that those
 who reached the seventh were pronounced to be out of danger.
   The disease was introduced into Moscow by a communication with
 the Turkish army: it made little progress during  the  earlier part
 of the year, but became fearfully fatal with the advance of summer,
 and gradually  died away with  the  frost.   The mortality was tre-
 mendous.   Seventy  thousand  inhabitants were cut off in a few
 months, twenty-two  thousand in a  single month,  and sometimes
 twelve thousand in twenty-four hours.  Notwithstanding which, by
 cautiously blocking up every avenue, except  one,  to the  large hos-
 pital over which he was appointed physician, and  keeping a strict
 and constant guard at the entrance thus left open, although the build-
 ing was in the midst of the city, it was maintained perfectly free
 from infection, while the disease raged around it in every quarter.
   Mr. Jackson's  account of the plague at Morocco is in  perfect con-
 sonance with this description, though it contains a  feature or two
 in addition, which probably became more  prominent from the high-
 er temperature of the atmosphere.  " The symptoms of this plague,"
 says he, " varied in different patients;  the variety of age and con-
 stitution gave it a like variety of  appearance  and character.  In
 some it manifested itself by a sudden and violent shivering, in others
 by a sudden delirium,  succeeded by great and unquenchable thirst.
 Cold water was  eagerly resorted to by the unwary and imprudent,
 and proved fatal  to those  who indulged  in its  momentary relief.
 Some had one, two,  or more  buboes,  which formed  and became
 often as large  as a walnut,  in the  course of a  day; others had a
 similar number of carbuncles ; others had both  buboes  and carbun-
 cles, which generally appeared in the groin, under the arm, or near
 the breast.  Those who were affected with a shivering, having no
 bubo, carbuncle, spots (vibices or maculae latae,)  or any other disfi-
guration (eruption,) were invariably carried off in less than twenty-
four hours ; and  the body of the deceased  became quickly putrefied,
so that it was indispensably necessary to bury it in a few hours after
 dissolution.
  " The European merchants shut themselves up in their  respec-
tive houses, as is the practice in the Levant.   1 did not take this
precaution, but occasionally rode out to take exercise on horseback.
My daily observations convinced me that the epidemy was not caught
by approach, unless that approach was  accompanied by an inhaling
 of the breath, or by touching the infected person." 
CE. IV.-SP. I.]        SANGUINEOUS  FUNCTION.             431

   This last remark is in strict agreement with the  observations  of
the best medical writers of modern times who have witnessed the
disease in different countries and climates: and the wholesome prac-
tice of drawing a  line of demarcation, and thus cutting off all com-
munication with the sick, is founded upon the same view.  M. As-
salini traces the progress of the plague among the French army  in
Egypt with great care, and asserts that even  those  who associated
with the sick  were seldom infected unless inmated in their rooms:
and  instances  the  small  degree of  danger  there  is  from  casual
intercourse, by showing how very rarely the medical attendants suf-
fered.
   Yet fresh persons are far less safe than the stated inhabitants  of
an iufected place,  who have been gradually inured to  the influence
of the morbid miasm.  Families, says Mr. Jackson, who had retired
to the country to avoid the infection, on returning to town, when all
infection had apparently ceased, were generally attacked and died..
After the mortality had subsided  at Mogadore, a corps of troops ar-
rived at the city of Terodant in the province  of Suse, where the
plague had been raging, and  had subsided:  these  troops  after  re-
maining three days at Mogadore, were attacked with  the disease,
and  it raged exclusively among them for about a month, though they
were not confined to any  particular quarter, many  of them having
had apartments in the houses of the inhabitants of the town.
   As in the plague of Athens and of London, continues  the  same
author, " the mortality was so great that the living noi having time
to bury the dead, the bodies were deposited or thrown together in-
to large holes, which  when nearly full,  were  covered over with
earth.  Young, healthy, and robust persons with  strong stamina,
were,  for the  most part, attacked first, then  women and  children ;
and, lastly, thin, sickly, emaciated, and old people."  The depress-
ing passions of fear and grief had also a strong predisposing effect:
a few suffered twice.   Morocco  lost a thousand upon an average
daily, where,the infection was at its height, being about the maximum
that  fell at London ;  Old and New Fez, from twelve to fifteen hun-
dred :  Terodant, about eight hundred. The  total loss sustained in
these three cities,  and in Mogadore, was estimated at one hundred
and twenty-four thousand five hundred souls.
   In the regular progress  of the disease,  buboes make their appear-
ance first, and about the second or third day  from the attack; then
carbuncles and ignis sacer, if either of these occur at all; and, lastly,
as the  danger  increases, petecchiae  and vibices.  But, as already ob-
served, where the  plague shows great malignity  from the first, it
opens with petecchiae and vibices, and sometimes kills in a few hours
even before these  have time to appear.
   Buboes, in the opinion of all the practical writers, or nearly with-
out an exception, are a critical mark of the disease, and the natural
means  of conducting it to a favourable termination : but in  order,
says  Mertens, to their proving beneficial, they must undergo perfect
suppuration.   In many instances they neither inflame  nor become 
432
HJEMATICA.
[CL. I1I.-0R. III.
painful; and in others they suddenly disappear after having reach-
ed  the  size of walnuts.   In the former case  they afford no re-
lief, in the latter death is almost sure to follow speedily.   The ear-
lier they make their appearance the better;  and upon a free sup-
puration they certainly render the patient  less susceptible of the
disease  afterwards.  In the opinion of M.  Sotira, indeed, and of
most of the French medical staff appointed  to the  Egyptian expe-
dition, they prove an  indemnity for life:  yet the examples of a se-
cond attack are too numerous to allow us  to adopt this opinion as a
general rule.
  Mr. George  Smith, surgeon of the Russian Imperial Land Cadet
corps of nobles, was twice a sufferer from the  plague at Bucharest
in the year 1772, as 1 think, and had the  rare privilege to recover^
from both assaults.  But that an exemption for a considerable term of
time is hereby very generally obtained, is established by innumera-
ble examples, of which it may be sufficient to quote that of M. Ma-
thias Degio, one of the surgeons  attached  to the  same  establish-
ment.   " Perceiving," says Dr. Guthrie, " the gentlemen of his
profession condemned, in a  manner, to death if punctual in their du-
ty, he had the resolution to inoculate  himself for the plague in a
full confidence  of its  efficacy;  and  ever afterwards found  himself
invulnerable, while his companions around him were falling victims
to its fury."*
   Of the efficacy of inoculation from the  virus of a buboe there can
be  no question; and we have hence a sufficient proof of the specific
character of the eruption;  but it is not always a successful efficacy;
and, even where  it is so, as the extent of the immunity is not suffi-
ciently ascertained, inoculation for the plague is by no means to be
recommended.  We are told by Mr. (now Sir John) Webb of a bold
experimenter in the person of a young physician and hospital sur-
geon attached to  the British army at Rosettain 1802, who, to deter-
mine the question whether the  bubonous virus of the plague be or
be not a specific  and propagable  poison, inoculated himself at El-
Hamed, on January 3d, twice by  friction from the matter of a bu-
boe, and once,  on the ensuing day, by incision.  He  was attacked
with rigor and  other symptoms of fever on the evening of the 6th
of the same month, which  proved to be the plague, became deliri-
ous on the 8th; and continued in  this state  till the evening of the
9th, when he  expired.t
   I gladly avail myself of  this authentic  narrative of the Director
General of the Ordnance Medical Department, published since the
preceding pages  were written, in confirmation of the general state-
ment here offered; and as  containing, if a feeling  of high  esteem
and friendship  have not unduly  biassed my judgment, one  of the
  * Guthrie's Observations on the Plague, &c. in Edin. Med. Comment. Vol. vm.
p. 348.
  t Med. Trans. Vol. vi. Art. vm. 
fSE. 1V.-SP.  I.]
SANGUINEOUS FUNCTION.
433
 most valuable documents we possess on the subject;  particularly in
 respect to the best practical means of opposing the influence of this
 desolating scourge upon a large scale.
   Sir John  Webb's narrative  embraces the history and progress of
 the  plague  as it  appeared in the  British  army employed  in  the
 conquest  of Egypt in the years 1801, 1802, and 1803, during  the
 whole of which time  he was present and actively engaged in arrest-
 ing  its  course : and  it justifies us in drawing the following conclu-
 sions.  Firstly, that the disease is specifically contagious.  Secondly,
 that the atmosphere of contagion is very limited; and that hence it
 is by no means difficult to avoid being infected.  Thirdly, that  the
 disease makes its attacks with very different degrees of malignity, at
 different  seasons of the year, and on different constitutions. And
 fourthly,  that those  who reside  in a place in which the plague
 exists, and have been gradually inured to the influence of the pesti-
 lential  miasm, are less disposed to be  affected by it  than those who
 are  fresh to its poison ; and, as in  the case of the  jail-fever, may
 carry about them, in  their clothef, effluvium enough to infect those
 who come within its  atmosphere,  while they themselves remain in
 a state  of health.
   The  first  position  is sufficiently proved,  not only by the  lest of
 inoculation  just  adverted  to,  but  by numberless  other  facts; of
 which one of the most forcible is the following : A lieutenant of  the
 10th regiment of foot, residing in Alexandria, was attacked  with  the
 disease and conveyed within  the boundary  of the  quarantine.
 A rent having been  made  in his musquito curtain, it was taken
 without his knowledge by John Lee, a private, and  servant to  the
 lieutenant, who prevailed on the cenrinel to let him  pass, in direct
 violation  of orders, to another private of the same regiment of  the
 name of  William  Bower, to  be repaired;  after  which Lee  imme-
 diately carried it home, and at his own request accompanied  his
 master  into  the  pest  hospital, and attended  him till he recovered.
 On the fourteenth day after this visit of Lee to Bower, the latter was
 taken ill with very suspicious  symptoms,  which, on the idea that it
 was  an attack of plague, could be accounted for  by  no one till the
 application to repair  the  musquito curtain  was recollected by  the
patient.    The suspicions were confirmed on the next morning, and
in the evening he died.
  So long,  however, as the line of  separation  was faithfully
maintained,  and the sound  and  the diseased were thus kept distinct,
 there was scarcely an instance in  which  the disease broke  out
among the former.  I say scarcely an  instance, because an  anoma-
lous  case  or two occurred occasionally.  But such was the judgment
and the vigilance exerted from first to last, that the Board of Heaith
were able to trace almost every instance of fever to the source from
which it was derived,  notwithstanding the  difficulty  of maintaining
a rigid and permanent prohibition of all communication whatever.
 \nd  hence it is most probable  that the few exceptions to the general
  vol. n.                   55 
434
H.EMATICA.
[CL. HI.-OR. III.
fact proceeded from a disobedience of orders which the Board were
not able to detect.
   In general, Sir John  Webb observes that the course of the disease
is nearly the same every year, and equally varies in different seasons
of the year.  In  Egypt it  commences in November, at which time
it rages with its most deadly malignity, " and those who are affected
by it  sink into  the grave  almost without complaint."   It continues
its ravage with little abatement through the winter and the earlier
part of the spring,  when,  as the weather becomes warmer  by  the
approach of summer, its attacks are less frequent, its symptoms much
milder, and  it subsides  into a  manageable malady ; still, however,
retaining the characteristic test of glandular affection : and on  the
24th of June the Turkish government announces to the public its
supposed cc^ation by a discharge of cannon.
   Sir John, however, with great judgment,  entertains  doubts of its
entire cessation even then or at any lime ;  and brings a  proof or
two of its existence during the period of official emancipation.  In
few words, he conceives the plagfte to exist  in  Egypt as the  small-
pox  exists  in  England;  only, from a greater regularity in  the
atmospheric changes of the  country, evincing a greater regularity
of epidemic flux  and reflux, operated  upon at the same time by
contingencies often difficult  to be developed;  and hence equally
varying in violence  and extent.
   That the miasm of plague, like that  of typhus, is sometimes
inert  upon those habituated  to its  influence, is obvious  from  the
following  fact.   " When our Pest establishment  at the camp was
broken up,  I discovered that the  Arab  servants, who  had been
employed in it, had secreted a great part of the clothing of the men
who had  died of the plague ; some of  which they wore with great
satisfaction and perfect  impunity."  I  have  noticed this effect of
habit  in the preceding  view  of the plague at Moga lore : and  to the
same  cause Sir John Webb ascribes it that the Chasseurs Britan-
niques, on  their first arrival at  Alexandria  from  Trieste, suffered
far more severely from the  disease than the troops  that  had been
stationed there for some months.
   How slightly the  disease makes its assault upon some constitutions,
may be inferred from the  case of one  of the sailors  of the  Major
transport, who was attacked  towards  the end of March with an
inguinal buboe, but was otherwise  in perfect health.  " The  man,"
says the  Director General,  " declared he had had it three days,
and attributed  it to cold.  I was, however, satisfied, after a careful
inquiry into his state, and an  examination of his leg and thigh  of the
same  side, that it was an  effect of pestilential contagion, but in its
mildest form.  He was, therefore, placed in a separate tent,  and  a
gentle aperient was administered, which was all the medicines he
required.   On the 2d  of  April I found the  swelling had  begun to
diminish, which it continued to do until it entirely disappeared."
   The following description is  of a  different character.   It is
written with a touching simplicity that does credit to  the author'*; 
GE. IV.-SP. I.]
SANGUINEOUS  FUNCTION.
435
heart, and will not be read without feeling by the  most torpid.
" As I approached the beach to examine them  (the  sick  and sus-
pected of the Major transport,) the first object that presented itself
was a young woman supported  in  a   chair (Francisca  Kennis,)
moaning under oppressive  disease.  She stared  wildly about, quite
insensible  to  every  object around  her, and there  was a muddy
glistening in her eyes, which  I had seen described, but had never
before observed.   Her husband stood over her in the deepest distress,
and held a lovely infant to her breast,  who  tranquilly sucked the
poison  that soon  afterwards destroyed  him.  I feared at first that
force  would have been necessary to separate the father from his
wife and  child,  but he at  length  yielded to  entreaty,  and, was
removed from the infection, though  too late to save his life.  She
was conveyed to the Pest  Hospital, where  she  soon expired ; and
the child was confided to an Arab, who fed and watched over it with
the greatest care.   On the  28th of March, the fifteenth day after the
separation took  place, the infant was  attacked with plague, and
languished until the  14th  of April,  when  death  terminated  his
sufferings."*
   Upon an average, from  a table  of the general return  of the loss
sustained by  the British army from the  plague, during the conquest
and evacuation of Egypt, from the 8th of March 1801 to the 8th  of
March 1803, comprising just two  years, it appears that the  whole
number of sick  was 660:—of whom 361 died, and  299 were dis-
charged cured : making the deaths  rather more than half the number
attacked.  And  further,  that  of the  above 660, 612 were  seized
between  March  8th, 1801, and  June  30th, 1802,  being  nearly
sixteen months ; and only 48 between July 1st, 1802, and March 8th,
1803, including the remainder of the time : a result which reflects a
very high degree of credit  on the means resorted to on the occasion,
and on the vigilance and activity with which they were carried into
execution : 361 being the entire loss sustained from this fatal scourge
operating through a  period of two  years : whilst  in the French army
in the same  quarter, as we learn from M. Desgenettes, not more
than one in three  of those that  suffered were fortunate  enough  to
recover.
  Such is the history of plague as it has shown itself in  different
ages and parts  of  the  world, collected from the writings  of unim-
peachable eye-witnesses of  its progress.   In the  midst  of  many
discrepancies  it exhibits a sufficient  identity of charicter;  and I
have dwelt upon  it the more largely,  because, from the time  of
Dr. Cullen to the present day,  its  discrepancies have been chiefly
attended to.  And  hence, while some  writers of respectability have
attempted to  divest it of one, and  others of another of its peculiar
and most striking attributes, as that of contagion,! or that of  atmos-
  * Loc. citat. p. 148.
  t Lange  Rudimenta doctrinoe  de peste.—Magirus, Von der Pest.—Maclean,
Results of an Investigation respecting epidemic and pestilential diseases, includin»
researches in the Levant concerning the plague. 
436
H/EMATICA.
[CL. I.l.-OR. 111.
pheric influence,* some  have been  equally inclined to sweep the
whole away at once, and to reduce it to a  mere modification ot
typhus or some other fever of great  malignity.t
  From its history, then, let us endeavour  to  collect its pathology,
or the laws by which it is governed, and which connect it with or
separate it from other exanthems.
  In the first place,  it is  obvious that the  plague, like many other
febrile eruptions, is under the occasional influence of various con-
comitant circumstances that give a considerable diversity to many of
its features.  Its proper fever is an acute typhus ; but even this, by
the constitution of  the individual,  or the peculiar state of the
atmosphere, sometimes changes  to a  remittent, and even an inflam-
matory type.  So the measles and small-pox, whose proper fever is
a cauma, sometimes change,  as  we  have  already  seen,  into a
typhus or synochus.  The final  end of the fever in plague, as in
other exanthems, is  to restore the body to health by throwing the
morbid ferment to the surface in a specific way.  And, as in other
exanthems also, a very small degree  of fever is requisite for this
purpose.  And hence we find that wherever the disease runs through
its progress kindly,  the  fever  is slight in  degree  and  short  in
continuance ; and the specific eruption shows itself in its perfect
character.   In the small-pox  we  sometimes find  scarcely any erup-
tion, and very little disturbance  of the system  ; and the same  benign
disposition is occasionally found to attend the plague ; for the soldier
who is  struck while in the ranks with a sudden shock, or m'arop,
as the Arabians call  it, and is taken  to the hospital on one day, has
in a few instances, by proper treatment, passed  through the  febrile
assault in three or four hours and resumed his station the day after:{
the disease in such cases evincing the same rapidity of attack and
recovery as we have already noticed in that  tremendous  and fatal
scourge, the spasmodic cholera of India, to which the  plague bears
a near resemblance in many respects.
  jS"ext, the proper eruption of plague is that of buboes ; and where
these alone arise, and  in their  proper period,  the disease  is not
accompanied with much  danger. They are always  a  favourable
sign, and seem to afford the longest indemnity against future attacks.
When the fever is  more considerable, carbuncles,  the  jimmerat
of the Arabians, are thrown out at the same  time  over different
parts of the body;  and there is in this case  always great debility,
which is probably the cause of their appearance, and a considerable
degree of danger.   And if the fever run  still  higher, the  danger
will  be  proportionably increased, the proper eruption of  buboes
  * Sir Brooke Faulkener.—Tully, Hist, of Plague in the Islands of Malta, Gozo,
Corfu, &o. 8vo. 1821.                                         '     '

  t Dr. W.  Heberden,  Observations on the  increase and  decrease of different
diseases, particularly the plague, 8vo.  1801.—Dr. Hancock, Researches into the
faws and phenomena of pestilence, &c. 8vo. 1821.
  X Edin, Med. Com. Vol, in. p. 3f>2. 
£E. IV.-SP. I.]       SANGUINEOUS  FUNCTION.              637

may perhaps be supprest, and carbuncles  alone be found, highly
malignant,  and  secreting  a most acrid and corrosive ichor  which
burns as it  oozes and spreads about, and occasionally forms extensive
trails of painful and distressing sores.
  But the fever is  often still more  acute, and especially, for a  rea-
son we shall presently notice,  when  the disease earliest appears
among a people ;  and the danger may be  imminent from the first
shock.  The typhous  symptom*  are here of the most  malignant
nature; there is a sudden and almost utter exhaustion of sensorial
power without the smallest means  of recruit: all the larger viscera
are disturbed in their functions, the head, the heart, the lungs, the
stomach, and the liver; some overwhelmed with congestion, others
sinking and powerless, as though the  morbid virus were translated
from the surface to themselves; the only active principle through-
out the entire  system being that of  fever itself;  which  increases
with the increase  of the general mischief, and, like a house on fire,
gathers fuel from  the downfall of the fabric.   All the  symptoms of
putrefaction make an early  appearance, and appear at the same
time under these circumstances;  the animal spirits fail and are de-
spondent ;  the  respiration is anxious and feeble; the stomach faint
and sinking, or the brain comatose; purple  stigmata and vibices are
scattered over the body; and the patient is destroyed by the incur-
sion of the eruptive fever, as often happens in the small-pox, before
 the specific tokens have time  to show themselves.
    Of the primary source of plague we are  in as much uncertainty
as  in respect to that of any other exanthem; it appears,  however.
to  have a just claim to a higher antiquity than any of them; for we
have already seen that it was  known in an  early era to the Greeks,
and that histories  of it, as it has shown itself in different ages and
countries,  have descended in  a regular  stream of Greek, Arabic,
Roman, and neoteric  writers  down  to our own day.  That,  like
other exanthems, it consists in and is propagable by a specific virus
is unquestionable ;  for we have also seen that it has often been put
to  the test of inoculation ; and, like  most  other exanthems also, it
appears to be dependent for an extensive spread upon the same ac-
cessories as give rise to febrile miasm or contagion ; and which, as
already noticed, are for  the  most part  the  common  auxiliaries of
putrefaction.*   Whether any combination of these be  capable  of
originating it of themselves either  without or within the human body,
 or whether it be only propagable  by a stream of hereditary descent
from primary  matter  communicated from place to place, is  a pro-
blem to the present hour; though it  is probable that the law which
in  this respect governs  most of the other exanthems as measles,
 small-pox, and scarlet-fever, governs the miasm of plague also: for
 all of them, while derivable  by communication with the affected,
 seem, at times, to have  assumed the form of epidemics.
    In deducing the more obvious  laws that regulate febrile miasm,

               * See Vol. n. p. 52. 
438
H^MATICA.
[CL. lll.-OR. HI.
I observed at some  length that whenever originating from the hu-
man body itself, this miasm does not seem to be very volatile and is
soon dissolved  or decomposed in an atmosphere of pure air :* and
we have since had occasion to apply the same remark to the speci-
fic miasms of all the preceding exanthems.  I have now to observe
that it applies especially to that of plague, whose sphere of infec-
tion in pure air appears to be more limited than that of any of the
rest; on which  account, indeed, it has been held by many who have
practised in the field of this disease to be communicable  by contact
alone.   Such, in truth,  seems to be the  surest way of communica-
tion, and may in all common cases be regarded as  a way  altogether
irresistible : but it is not the only way.   In the pure and healthy air
of Malta, during the irritation  of the plague in 1813, it was almost
the only mode of transmission,  and hence the readiness with which
it was subdued by the rigid line of quarantine, which was so wisely
proposed by the medical officers, and enforced by Sir Thomas Mail-
land.   But several of the most intelligent residents on the spot, and
even Mr. Tully himself, who  in his work on  this subject  has held
up contagion as the sole mean of propagation, have admitted to me
in conversation that the disease might be  received by the breath of
the infected without contact, upon a very close intercourse.   Sir B.
Faulkner's opinion upon this point is in perfect union with Mr. Tul-
ly's : " It is communicated," says he,  " only by contact or close as-
sociation with the person or thing infected."t   And in consequence
they admit  that the air, even  in its  purest  state, may  become a
vehicle of communication, though to a very short distance, and pro-
bably for a very short period of  time  after being impregnated:
since, as already observed, the miasm of plague  dissolves in pure
air with great rapidity.
  When, however,  the atmosphere is stagnant or already loaded
with foul effluvia of any other kind, especially such as proceed from
the filth of close  or  crowded rooms, or the putrescent  decomposi-
tion  of animal or vegetable substances, as no modification of febrile
miasm, we have had reason to state antecedently, dissolves readily:
and consequently the seeds of such disease may continue floating for
a considerable  period of time, and  be driven by currents to some
distance in full possession of their specific mischief; and hence, even
a sporadic fever may be converted into an epidemic.
  It is in  this way  that plague appears in many cases to have ex-
tended itself; for it would  be unjust to the character and good sense
of a  cloud of intelligent witnesses to deny that this disease  some-
times also assumes  the form of an epidemy.   But I believe it will
be found an universal fact, that it has never exhibited itself in this
form except when  aided by the above  auxiliaries.  Thus much is
certain, that it  has always raged  with most violence and  to the
greatest  extent in cities and districts where the atmosphere has
* Vol. ii. p. 52.
t Minutes of Evidence before the Select Committee of the House of Commons. 
•;e. iv.-sp. l]
SANGUINEOUS FUNCTION.
439
been least pure, the human frame  most debilitated, and the tenden-
cies to  putrefaction strongest and  most multiplied, as in times of
famine or any other general distress,  and in  the close and squalid
quarters of the  poor of every city into  which it has found  an en-
trance, if it have not even originated there.
   This fact,  indeed, is so common, that while  many writers have
contended  that  plague can  onlj be propagated by actual contact,
others, of equal authority, have maintained that the disease is alto-
gether an epidemic, as  directly dependent upon the state and con-
stitution of the  air as any epidemic whatever;  and that to attempt
to cure it by a mere  interdict of communication between individual
and individual is equally weak and wicked.  The view now taken of
the disease is calculated to reconcile these conflicting opinions, and
to  bring into a state of amity the  most sturdy adversaries in  the
contest.   In enforcing the line of quarantine at Malta,*  Sir Brooke
Faulkner most  wisely  took especial  care to  enforce at the same
time a rigid  attention to purification of every kind, and I shrewdly
suspect that, without the latter, his cordon would  have been but of
little avail.
   Thus far the  ordinary course of  plague  does not  essentially vary
from that of most of the exanthems we have already  considered.
The general laws of any one are  those of the whole :  they are all
deflected,  and exhibit  some  variety of features by particular cir-
cumstances ;  but each, to an attentive  eye, gives sufficient proofs of
identity in the  midst of every modification, and is specifically dis-
tinguished from the rest.
   There are two or three properties, however, which, if not pecu-
liar to the plague, are indented upon it far more strikingly than upon
any other disease of the same order, or perhaps of any  order what-
ever : and we will next proceed to  a brief examination  of them.
   The ordinary mode of. infection on exposure to an  exanthema-
tous patient is, by inhalation or deglutition ; probably by the former;
for variolous  contagion has been swallowed in the way of experi-
ment without  producing any influence.   How far  any  other  virus
besides that of the plague is receivable by  the pores of a sound skin
is to this hour a matter of doubt.   In the case of plague, however,
there ought  not to exist the shadow of a doubt;  for,  though  the
miasm is probably communicable within the sphere of its activity,
by the mouth  or nostrils, direct contract or absorption  by the skin
forms the ordinary means of its  conveyance.   Upon  this point, al-
most all the writers of authority, who  have been professionally en-
gaged in opposing its progress, are  concurrent.  And hence, again,
whatever obstructs or corrugates the  mouths of the  cutaneous ab-
sorbents  becomes a certain anti-loimic.  Oil seems to  do this most
effectually;  it was accounted  " the sovereignst  thing on earth" in
the last pestilent ravage at Malta ;  and Mr. Tully has informed me
that there  was  no instance  of an attendant on the infected having

  * Treatise onthe Plague, by Sir Arthur Brooke Faulkner, M.D. 8vo. 1820. 
 440                    HjEmatica.            [cl. ih.-or. hi.

 received the contagion so  long as he was regular in thoroughly il-
 lining himself with oil, wearing a dress soaked in oil, or a covering
 of oil-skins.  And to the same effect is the evidence of Sir Brooke
 Faulkner, physician to  the forces at  Vlalta in 1813, before  the Se-
 lect Committee of the  House of Commons, June 14, 1819,  who, in
 answer to the  question " How were the military attendants pre-
 served ?" replied. " with respect to the Pest  hospital in which ' at-
 tended, they were, in  my opinion, preserved by wearing a  dress of
 oiled silk, which prevented the possibility of any contact of  infected
 matter with the skin, and probably, also, b\  its promoting free and
 copious perspiration, and, in consequence, preventing absorption.*'*
   To  the same effect it has been asserted by Mr. Baldwin of Cairo,
 that among  upwards of a million of inhabitants carried off  by the
 plague in Upper and Lower  Lgvpt during the space of four years,
 not a single dealer in oil, so far  as he could learn, had  fallen  a sa-
 crifice to it."t  A simdar remark is made by Mr. Jackson  respect-
 ing  the crolies or  labourers  in oil-warehouses  during the Barbary
 plague just referred so.  In that of London in  1665, it is specially
 observed by Baynard, and most of the writers, that the trades chiefly
 exempted were tbose of  oilmen,  fishmongers, tanners, bargemen,
 and  watermen: the first three  evidently protected by the greasy
 viscidity that covered  the hands and  dress generally; and the  last
 two  by living separate  from  the scene of contamination, as though
 cut off by a quarantine.   While, on the contrary, it has been quite
 as generally remarked that the descriptions of persons  most expos-
 ed  to  infection are bakers, cooks, and smiths, the  pores of whose
 skin are  kept in a state of perpetual irritation and relaxation from
 their respective employments.
   How far an habitual exposure to the miasms of other  exanthems
 torpefies the skin to their action,  or  whatever other  organ affords
 them an inlet;  or how far the system at large  may be thus torpefied,
 has  not been determined with  any  degree of satisfaction.  That
 stimulants of most kinds have a tendency to produce such torpitude
 and inirritability is unquestionable; and that the miasm of gaol-fever
 has occasionally done it, will  not soon be forgotten in  the courts of
judicature of our own country.   It is hence probable  that the efflu-
 vium of exanthems, in  general,  is possessed  of a like power.  But
in the case of plague the fact seems to be  unequivocally and  most
strikingly established ;  for we find in every country, after it  has
 raged for a certain number of weeks or months, that the disease is
 both caught more sparingly, and exercises far less  violence, at  least
 upon those that have been exposed to its aura; for upon new comers
 or strangers  it still retains its  virulence.   The history of almost
 every  plague may be taken in confirmation of this  remark; but it is
 particularly established by numerous facts already quoted from Sir
  * Copy of \linutes, &c.  As also Sir A. B. Faulkner's Treatise on the Plague,
Sic.  Appendix, p. 16, 8vo. 1820.
  + Travels, &c. Chap. xvn. 
GE. IV.-SP. I.]        SANGUINEOUS  FUNCTION.              441

John Webb  and Mr. Jackson.  It is highly  probable, that if the
corps of troops which, after the mortality had subsided at Moga-
dore, arrived there from the city of Terodant  in the province of
Suse, where the plague had been raging and had subsided, had remain-
ed at Terodant, it would  have continued to escape.  But it lost its
immunity by an exchange of contaminated for pure air in  the course
of its journey, and the organs, having acquired their wonted irrita-
bility and susceptibility, were as open to infection as those of fresh
persons.
   The  acquisition, then, of a growing torpitude to the action of the
pestilential effluvium beneath an habit of exposure  to its influence,
seems unquestionable ;  and  puts us in possession of one mean of the
progressive subsidence  of this tremendous scourge, after having oc-
cupied  a town or district for a certain period of time.
   But  there is an additional cause of its cessation, which is equally
striking, and forms another  of the  peculiar features of  this  com-
plaint.  As a particular state of the atmosphere, such, for instance,
as its being saturated with foreign corpuscles from decomposing ani-
mal filth,  renders it a bad solvent of pestilential miasm, and conse-
quently a ready vehicle for the spread of the disease, a particular
state of the atmosphere of some other kind seems to possess a  pow-
er of dissolving the effluvium instantaneously, in many cases, and of
diluting its virulence in others.  Of the  immediate nature of this at-
mospheric change we are in a  very considerable degree of  igno-
rance, but of the general fact there  is not a quarter  of the world
that does not furnish us with examples : so that all of a sudden the
scourge that  has hitherto  been sweeping off one or two thousand
inhabitants of a city every day either totally vanishes, or drops its
mortality,  and  only continues in a form  so  mild  as  to excite no
alarm.  Dr. Hodges notices  this sudden  change very particularly in
the plague of London.   " In the beginning*!' November," says he,
" people grew more healthy, and many  came into  the city without
fear ; so that in  December they crowded back as thick as they  fled :
and such confidence was now inspired that many went into the beds,
v/here persons had  died, before they were  cold, or cleansed  from
the stench  of the diseased ;for the nature  of the  disorder  was chang-
ed.*   " Even the physicians themselves," says  another eye-witness
of the  same  pestilence,  "were surprized: wherever they visited
they found their patients better.  Either they had sweated  kindly,
or the tumours were broken, or the  carbuncles went down, and the
inflammation round them changed  colour, or the fever  was gone,
or the  violent  head-ache assuaged, or  some good  symptom was in
the case :  so  that in a few days whole families that  expected death
every hour were revived and  healed,  and  none died at all out of
them."t
* Loimol. p. 27.
t Journal by H. F. p. 250.
vol..  II.
56 
442                      HJEMATICA.          [CL. III.-OR. Mr-

  Alpinus speaks in the same manner of the sudden decline of mor-
tality in  the  plague of Egypt: "In the month of June," says he,
" to whatever degree pestilence may be raging in Egypt, as soon as
the sun enters Cancer it ceases  entirely."  And Dr. Russell confirms
this remark as follows :—" It is  agreed on all hands that about  the
24th of June, at Cairo, there is a remarkable  sudden alteration id
the contagious property of the plague, as well as in the malignity of
the disease itself, to whatever cause it is to be  ascribed; and Alpi-
nus's remark, that at the same time it ceases, the furniture in infect-
ed houses suddenly loses all power of communicating the disease to
the inhabitants, so that health and tranquillity are at once restored,
agrees in some measure with the general experience of other places
in Turkey, where it is well known houses or goods undergo little
or no purification."*  Mr. Bruce speaks to the  same effect: " The
Turks and Moors, immediately  after this day, expose in the market-
places the clothes of the many thousands that have died of the plague
during its late continuance; and though these consist of fur, cotton,
silk, and woollen-cloths, which are stuffs the most retentive of the
infection, no  accident happens to those who wear them, from their
happy confidence."   And we are hence able to enter more fully into
the meaning of a passage  already quoted from  Sir John Webb, in
which he tells us that on the approach of summer  the  plague sub-
sides into a manageable malady,  and  that on the 24th of June  the
Turkish  government announces to the  public its supposed cessation
by a discharge of cannon.
  Unless, therefore, we withhold, most unjustly, all belief in  this
accumulation of unimpeachable evidence, it seems impossible not to
admit that the state of the atmosphere  is connected with the decline
of the  plague, and consequently with its previous progress :  while
its dependence upon a specific  miasm  seems equally clear from its
occasionally commencing in the healthiest, as  well  as in unhealthy
seasons ;  though most frequently, and most fatally, in the latter.  In
the plague of London, as we have already seen, the disease followed
upon a malignant epidemy; in that  of Athens,  the  preceding year
had  been so  peculiarly healthy that  mankind seemed to have ac-
quired an exemption from complaints  of every  kind.   In that of
Egypt, it makes a regular return whatever be the constitution of
the season.
  In entering upon the medical treatment of plague, I regret that I
am not able to give the judicious plan, in conjunction with its re-
sults, that was adopted for the British army in Egypt.   The care of
the Pest  Hospitals did not fall within the range of Sir John Webb's
department,  but I  availed myself of  his  friendship  to  solicit  in-
formation upon this subject from  his colleague  Dr. Buchan, who, 1
have  reason to believe, had made a journal of very valuable notes
in relation to it.  The public will hear, with regret, that this infor-
mation is incommunicable  from the  destruction of a great part of
* On the Plague, B. in. Ch. v. 
OE. IV.-SP. I.]      SANGUINEOUS  FUNCTION.              443

these minutes, which followed the fate of Dr. Buchan's clothes and
bedding at the time of his quitting the hospitals.
  Respecting the proper plan to be  pursued, there is still  some
controversy.   Early, copious, and  even repeated  venesection was
at one time, and by very high authorities, recommended in this dis-
ease, and  especially by Sydenham  at  the  commencement of the
plague of London in 1665 and  1666, before  the appearance of any
eruption.   Like Dr. Rush, in North America, respecting  the yel-
low fever, he  was stimulated by the bold determination  of  quelling
this formidable enemy in its very onset, and before it should  have
made a fatal breach in  the  constitution.  This practice, however,
has been  far less successful, and therefore less persevered  in,  with
regard to the  plague, than with regard to the yellow remittent. Dr.
Mergens says, he  would never advise its being  resorted  to: and
even Sydenham hesitated as  he became more experienced.   " But
though,"  says he, "I  approve and have'often experienced  the uti-
lity of bleeding, yet for several reasons I  prefer  the dissipation  of
the pestilential ferment by sweat,  because sweating does not in the
same degree prostrate  the  patient's strength."*  Where  there  is
great and threatening congestion in a large or vital organ, bleeding,
and bleeding freely, should certainly be employed, for this symptom
alone  would lead to a fatal issue.   But the practice  must form an
exception to the general rule, and not the rule itself.
  The use of external cold by the application of sheets of pounded
ice to the body generally, has been also tried, but with no satisfac-
tory result.  It has, indeed, been chiefly confined  to  Russia, under
the vigilant eye of M.  Samoilowitz.   How  far it might succeed  in
warmer climates is uncertain, but ablution with cold water  offers a
fairer promise.  A brisk emetic, given at the commencement of the
attack, has often proved of the  utmost advantage.   M. Degio,  to
whom I have already adverted, affirms that  he has seen men, sud-
denly cut  down by the disease when on duty, as though shot  by a
musket-ball, so completely recovered by an  emetic given instantly,
as to be on duty again within twenty-four hours afterwards.1   If the
nausea and bitter taste in the mouth be not removed by a first  eme-
tic, a second, and even a third is  often prescribed; and, when the
symptoms are urgent, at a distance of not more  than four or five
hours  from each other.  And this plan is found to produce far less
exhaustion than that of purging which the patient is often unable  to
support.
  After evacuating the  stomach, and hereby exciting a determina-
tion towards the skin, the cutaneous action  is  to be maintained by
aciive and cordial sudorifics, which, indeed, constitute the  ordinary
plan of the present day.   For cordials, there is the utmost necessity :
the debility is, from the first, extreme and threatening,and the vascular
  "'  Loco citato.
  t  Substance of notes taken  at the Russian army during the prevalence of the
Plague. Sec Edin. .Med.jCom. Vol. vm. p. 352. 
444
ll.EMATICA,
[CL. IH.-OR. III.
 action must be supported at all adventures.  Even Sydenham, who
 at one time hesitated as to  the use of them upon  theory, in which
 he did not often indulge, was obliged to admit  their beneficial ef-
 fects, though he regarded the practice as hazardous.  With respect
 to sudorifics, the concurrent voice of all physicians in all countries
 is in their favour.   Diaphoresis is, indeed, the evacuation that re-
 lieves most  certainly and  most effectually; and  it should be main-
 tained by warm, diluent and  supporting drinks.   James's  powder
 employed without cordials  does not appear advisable.  It was very
 largely administered at Moscow, but, according to Dr. Mergens, with
 no particular advantage.  In many cases, the warmer opiates as the
 opiate confection, have been found serviceable, assisted with  cam-
 phor and ammonia, and blisters repeated in succession.
  As  oils of all kinds applied to the surface of the body have been
 found a good preservative against the absorption of the contagious
miasm, it has been also had recourse to, and employed in the same
manner as an antidote when the disease is present, and particularly
in the east where the zeit jagghy, or olive oil, has been regarded
almost as a specific.   Mr. Baldwin affirms that he  made use of it in
this form very  extensively at Cairo, and with great success: and it
is usually employed in Barbary and at Constantinople.  The French
physicians, however, do not seem to have relied much upon its vir-
 tue.   M. Sotira suggests that Mr. Baldwin's benevolence in  the dis-
 tribution of oil  for  this  purpose was occasionally abused, and  the
cures by oil exaggerated and multiplied by those who wished to
have oil gratis.  M. Assilini, however,  inclines  to a belief that it
 may be useful; and it is most pointedly recommended by father Louis
 of Padua,  director of the  hospitals  at Smyrna.   The application
should be accompanied with  a long-continued friction;  and,  when
successful, is followed in about half an  hour by a perspiration pro-
fuse  and general,  and which affords immediate  relief.  It is not
difficult to reason  upon the subject: the oil  probably obstructs the
pores of the skin, and prevents the  escape of caloric, which,  aided
by the friction, accumulates on the surface,  and shortens, or  alto-
gether prevents, the  shivering fits, which are otherwise very se-
vere.  Sir Brooke Faulkner admits its sudorific power, but is by no
means friendly  to its use ; believing that even  by  this very power
it has often proved highly  injurious.  Yet  he does not  speak from
much personal acquaintance with  its effects; but tells us  that u a
gentleman who superintended the  health of  one of the districts of
Valetta, assured him that although  he had constant opportunities of
seeing oil frictions used by those  under his immediate orders, he
 was satisfied that it was  not merely useless as a  defence, but hurtful
 to the general health, by the debility which succeeded  to  the pro-
fuse perspirations which it occasioned."   Sir Brooke, in the  passage
 of his work now referred to, estimates its prophylactic virtue as low
as its  remedial,* and is thus far in  a state of direct antagonism, not
* Treatise on the Plague, &c. pp. 231, 232 
GE. 1V.-SP. I.]       SANGUINEOUS FUNCTION.             445

only with Mr. Tully, who  was afterwards Inspector  of  quarantine
on the same station, but with himself, at the time  of  delivering his
evidence before the Select Committee of the House  of  Commons;
an extract from which we have already quoted.
  In the remissions of the fever, the bark is  used in great abun-
dance, commonly  intermixed with port  or  other generous wines.
During the fatal plague which depopulated  the whole  of western
Barbary in 1799,  the Emperor Sidi Soliman is said to have had the
disease twice, and in  both cases to have derived  his cure  from a
free use of the bark : in consequence of which, he was never after-
wards  without a large supply  of it.  When buboes  or  carbuncles
appear, they are  always to be promoted and matured by warm cata-
plasms.
  Camphor, smoking tobacco,  fumigation  with  gum sandrac, and
the vinegar of the Four Thieves, are still largely  employed as pre-
ventives.   But the contagion,  as we have already observed,  is
not peculiarly active, and the  best prophylactics are  cleanliness,
pure air,  freedom from actual  contact, a liberal  diet, and cheerful
spirits. I may add  that vaccination has been repeatedly tried ;  but
has answered no good purpose.   Sir Brooke Faulkner, indeed, gives
a striking example of its failure, for " in a numerous family,'' says
he,  " who had been recently vaccinated, the whole fell sacrifices to
the prevailing contagion, with  the exception  of  the  parents  who
had never undergone the operation."*
                         SPECIES II.

               ANTHRACIA RUBULA.




TUMOURS NUMEROUS AND SUCCESSIVE; GRADUALLY INCREASING FROM SPECKS
  TO THE  SIZE OF  A RASP-BERRY : ONE AT  LENGTH GROWING  LARGER
  THAN THE REST ; CORE A  FUNGOUS EXCRESCENCE ;  FEVER SLIGHT: OC-
  CURRING ONLY ONCE  DURING  LIFE : CONTAGIOUS.

The term rubula, by which this  disease is distinguished in the pre-
sent work, is derived from the Latin rubns,  " a black-berry or rasp-
berry," in French framboise,  whence the common but barbarous
name of frambcesia, quite as objectionable  as that of scarlatina; and
which the author has thus attempted to exchange for an euphonous
and strictly classical term, in perfect accordance  with  the ordinary
law of diminutives,  which seems  to prevail through the general no-
menclature of exanthematous diseases, as rubeola, variola, varicella.
Treatise on the Plague, p. 233, 
446
HjEMATICA.
[CL. HI.-OR. III.
Perhaps morula, from morus, a mulberry, a  diminutive used in an
approximating sense by Plautus, might have been  somewhat more
appropriate, since the eruption seems to bear a nearer resemblance
to small mulberries than to rasp-berries.   But as this last plant has
laid a foundation for the vernacular name both  on  the African and
American coast, on the former of which it is called yaw and on the
latter pian or epian, both  importing rasp-berry ; and as the earliest
writers have, upon this authority, denominated it framboise or fram-
bcesia, I have not felt myself at liberty to deviate, from the original
idea.
   The  disease as it occurs in Africa and America, exhibits some di-
versity, and lays a foundation for two varieties  as follow:

x  Guineensis.                     Attacking infants and young per-
   African Yaws.                    sons chiefly;  and subsiding ac
                                   soon as the eruption appears.
&  Americana.                     Depascent;  and  destroying pro-
   American Yaws.                  gressively both  muscles  and
                                   bones.

   In the precursory remarks to the present genus, I have stated the
reasons for introducing this species  into  the  list of exanthems, or
febrile eruptions;  and  the history  of the disease  will  still further
show that it could  not with propriety have been placed under any
other division.  It is singular that we have no  decided account of
this malady among'the early  writers;  nor, indeed, any  account
whatever till after the  appearance  of syphilis ; whence, as several
of its symptoms, and especially when the bones  become affected,
bear a resemblance to those of syphilis, yaws have  been  supposed
by some writers to be a species of lues, and especially of that which
in Scotland is denominated sibbens or sivens, of which we shall treat
in the ensuing order: but  the  eruptive  fever and consequent efflo-
rescence, the indemnity from a second attack, as well as other symp-
toms, draw a sufficient  line of distinction.
  The  first variety  will often run  through its course favourably
without any medical assistance whatever; and is, indeed, often in-
jured by it when  incautiously  and  injudiciously interposed.   This
seems to be the primitive form, and thatu nder which it chiefly shows
itself in Guinea, and some other parts of Africa, where, as just ob-
served,  it is vernacularly called yaw or morbus rubulus.
  It commences, like the other exanthems, with the ordinary symp-
toms of fever, although they are usually more tardy in their pro-
gress.   Hence the precursory symptoms are languor, debility, head-
ache, loss of appetite,  rigor, and pain in the back  and loins, which
continue for a few days with evening exacerbations.  To these suc-
ceeds the specific  eruption; consisting  of successive  crops of pa-
pulae, at first not larger than a pin's head, but increasing in size with
every series till they acquire the magnitude of a rasp-berry or mul-
berry.   The smaller papula? become real pustules, and discharge an 
GE. IV.-SP. II.]       SANGUINEOUS  FUNCTION.             447

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, axilla?, 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 ojd 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 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 callu-
ses, which 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,  which 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 pati^^from  his associates,  to  whom he
will  otherwise assuredly conjHpcate 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 Phys. p. 643. cd. 1819. 
448
I-LEMATICA.
[CL. HI.-OR. III.
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  adviseable 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 wouid prove  as
beneficial as in the case of lues.   But  it is now  sufficiently  known
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 with advantage ; but it ought never  to  be  employed in any
other form.
  When the excrescences discharge a sordid ichor,  they may also
be stimulated with 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 what may be called a warm 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-
der 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 progres-
than the plague, is accompanied with a carbuncular eruption quite as
mischievous and disgusting, and more 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 intdHfet West Indies along with the
slaves  from the African coast; artd^ls here calied, 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. u. Art. lxxvi.
■I- Edin. Med. Coin. Vol. n. p. 90. 
GE. IV.-SP.  II.]
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-yaw, 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"!  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 where 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 which 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 warm balsamic  applications to the
sores, have not unfrequently succeeded, where  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.
        * Cl. in. Ord. n. Vol. n. p. 194.
        t Notes on the West Indies, Vol. II. Letter xxn.


vol.  n.              57
/ 
       CLASS  III.

H^EMATTCA
                         ORDER  IV.


                     DYSTHETICA.

                          (tachetits.

 morbid  state  of the blood or blood vessels ; 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, Av„s, lues,  or lyes.   None of these,
 however, exactly answer; 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
 JNosology, and it is not necessary to add to  the remarks there offer-
 ed.  1 he word dysthetica has hence been adopted for the purpose of
 avoiding contusion, and is justified by the eusthesia and  eusthetica
 (ET20E2IA  and EYS0ETIKA) of Hippocrates and Galen, importing
a "well-conditioned  habit of body," as their  opposite dysthetica,
 from the same root, imports  "an ill-conditioned habit," but a  habit
 as just observed, originating in, or dependent  upon the organized
parts or fluids  of the  sanguineous function.  Thus explained: it will
 be found to embrace  the following genera :

            1. PLETHORA.         PLETHORA.
            2. H^EMORRHAGIA.     HEMORRHAGE.
            3. MARASMUS.         EMACIATION.
            4. STRUMA.          SCROPHULA.   KINg's EVIJ
            O. CARCINUS.         CANCER.
            6- LUES-              VENEREAL DISEASE 
GE. I.]
SANGUINEOUS FUNCTION.
451
 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 J  OPPRESSION OF THE  HEAD, CHEST  OR  OTHER INTERNAL OR-
   GANS.

Plethora is seldom ranked as a disease, and hence seldom treated of in
a course of medical instruction.  From what cause this omission pro-
ceeds 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 ccfnsulted.
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
long as a due balance is maintained, and the proportion 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 double 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 
 4.V2                   HJEMATICA.              [CU- IH.-OR- IV-

 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 which the animal
 machine is reduced is  also  met another  way ;  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  with cases in which, from a peculiar  diathesis, the
 capacity of the vessels is unduly contracted, while  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 bal-
 ance 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 words, there must be  in both cases an
 excess of fluid or a plethora, though from very different, and what are
 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
 spatium, 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, while 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 vigo-
 rous 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 with an inordinate formation of blood in a con-
 stitution where  the vascular action is  peculiary  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 of 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.-sl\ 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 ENTONIOA.         SANGUINE  PLETHORA.
        2.  ----.----ATONICA.          SEROUS PLETHORA.
                         SPECIES I.

               PLETHORA  ENTONICA.

                   Sanguine plethora.

PULSE FULL, STRONG, REBOUNDING: MUSCULAR FIBRES FIRM AND VIGO-
                             ROUS.

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 absorbness,  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
HZEMATICA.
[CL. I1I.-OR. IV.
be prevented by the use  of refrigerants, 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 sanguineous  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 11.

               PLETHORA  ATONICA.

                      Serous plethora.

PULSE FULL, FREQUENT, FEEBLE :  V1T4L ACTIONS LANGUID ; SKIN SMOOTH
           AND SOFT ; FIGUkE 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 vig-
our and rapidity of action ; the secretions are all hurried forward in
their elaborations, and carried  off as soon as  produced.   In the sec-
ond, 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 which 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 teized 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
eupping or the use of the  lancet.   But, though the  distended and
overflowing vessels demand an abstraction of blood,  it should never 
GE. I.-SP. II.]
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 abund-
ant than usual; the  sedentary life should give  way 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 with advantage ; and the muscular fibres  will
become  firmer as the cellular  substance  loses its bulk.
   The whole, however, must be the  work of time; for although in
morals it is a wholesome principle that bad habits cannot too speedi-
ly 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 thrown 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 instantly
gave the man a Scot's quart of ale and  a gill of brandy, which was
his usual allowance for the evening,  he slept well and sound ;  the
next morning was free from delirium and fever; and, by a perse-
verance  in the same regimen, obtained  a speedy cure without the
least accident.*
* Edin. Med. Ess. Vol. v. Part 11. Art. xi.vi. 
 456                    FUSMAT1CA.           fCL' 11I'-°R- IVl


                      GENUS   II.

                    H.EMORRHAGIA.

                        hemorrhage

            FLUX OF BLOOD WITHOUT EXTERNAL VIOLENCE.

 The term haemorrhagia, or hemorrhage, is derived from the Greek
 xtftx, " sanguis," and pV*-*, " 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 pyrexia, 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 with 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 it-
 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 exhalents 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. K&MORRHAGIA ENTON1CA.    ENTONIC  HEMORRHAGE
     2.------------ATONICA.      ATONIC HEMORRHAGE. 
fcE. II.-SP. I.]        SANGUINEOUS FUNCTION.             457


                         SPECIES L

           HiEMORRHAGIA ENTONICA.

                   Entonic Hemorrhaae.

 ACCOMPANIED WITH INCREASED  VASCULAR ACTION: THE BLOOD  FLORID
                         AND TENACIOUS.

 *s the outlets of the body are but few, and  all of them communi-
 cate with numerous organs, we cannot a ways determine with strict
 accuracy from what particular part the discharge flows.  We have,
 however, sufficient reason for the following varieties:—

 x  Narium.              Entonic bleeding at the nose.
 6  Haemoptysis.         -------spitting of  blood.
 y  Haematemesis.-------vomiting of blood.
 3  Hematuria.          -------bloody urine.
 c Uterina.              -------uterine hemorrhage.
 I Proctica.             ------■  a"al hemorrhage.

    The great predisponent cause of active hemorrhage, wherever  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-
 o-an 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.  Ihus, some
  organs acquire developement and perfection sooner than others,  ot
  which  the head, peculiarly  large even in infancy, furnishes us  with
  a striking example : and, in the promotion of such developement,
  the flow 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,  we 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 suriace
  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 lite  Hae-
   moptysis, or spitting of  blood, takes place more commonly a few
   vears  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.  H.
58 
 458                    HiEMATICA.           [CL. III.-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 ami  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 with the observation of Hippocrates, who has
 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 which it may be presumed that the resis-
 tance to the passage of the blood from the arteries into the veins is
 greater in young animals than in old;  and while 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 with 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 portarum,  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 which has a ten-
 dency to produce the disease vicariously.
  Thus, 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. H.-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 weakness, 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.f  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, however, 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
what 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 when 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.1T  Tulpius
gives a case of chronic haemoptysis that continued for thirty years ;**
and others, instances of much longer duration.tt
   There is also  another reason for  an  early attention to spontane-
ous hemorrhages;  and that is,  the profuseness of the discharge •
  * Percival's Essays, n. p, 181.
  t Galen. De  Loc. Affect. Lib. iv. Cap. v.—Riverius, Observ. Med. Cent. iv.
Obs. 26.
  X Galen. De Loc. Affect. Lib. IV. Cap. v.—Borelli, Cent. i. Obs. 24.
  i  Schenck, Lib. vn. Obs. 124. ex Langio.—Hist. Mort. Uratislav. p. 58.
  ||  Schenck, Obs. Lib. hi.  Serm. n. N. 258.
  f Rhodius, Cent. n. Obs. 64.—Ab. Heer. Introduct. in Archiv. Archei.
  ** Lib. n. Cap. ii.
  t1 N. Act. Nat. Cur. Vol. i. Obs. I. 
460
HjEMATICA.          [cl. iil-or. iv.
which 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 :t and other writers  bring examples ol
its having proved fatal.
  The largest quantities, however, are usually lost from the nostrils.
Ten, twelve, and upwards of twenty pounds have  been  known  to
flowaway before the hemorrhage has ceased.  Bartholin mentions
a case of forty-eight pounds,^ Rhodius another of eighteen pounds
lost within thirty-six hours ;§ and a respectable writer in the Leip-
sic Acta Erudita, a third of not  less than seventy-five pounds with-
in ten days ;|| 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 which continued without cessation for
six weeks.1T
  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 precursors;  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 ;tt and Blancard, upon the ringing of bells :|f and

           * Voi. xlh.
           t Miscell. 1728. p. 1496.
           X Anat. Renov. Lib. ii.  Cap. vi.
           i Cent. i. Obs. 90.
           [| Act. Erudit. Lib. 1688. p. 205.
           It Dec. i. Ann. m. Obs.  243.
           ** Bruyerinus De Re cibaria. Lib. I.  Cap. 24.
           tt  Rhodius, Cent. m. Obs. 99.
           XX Blancard, Collect. Med. Phys.Cent. vi. Obs. 74. 
6E. II.—SP. I.]     SANGUINEOUS FUNCTION.                461

when 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 e^ (ap or aph) came to  be employed among the Hebrews 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, when
thus  locally  and spontaneously evacuated, has afforded,  on  some
occasions, a  wonderful  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 with  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  these
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 which we  should
force up  tents of lint moistened with 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-water, 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  iilined with moistened powder of charcoal, which
* Rhodius, Cent. i. Obs. 89. 
462
PLEMATICA.
[CL. III.-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 when
 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,!  probably from the cold sweat
 that so often attends such an emotion : and  Reidlin gives a case in
 which it was cured by sneezing ;f 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 hemoptysis or spitting of blood, it is not  always easy to deter-
 mine 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, dyspnoea, 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 lodgement, 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 in. p. 21.
t Panarol. Pentecost, v. Obs. 27.
£ Linn. Med. Ann. i. Obs. 24.
i Cent. m. 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 we  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 we  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 down.   The
incidental  causes are misformation of the chest; undue exertion of
the respiratory muscles,  whether in running, wrestling, singing, or
blowing wind-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 where ; but  to act  thus
they should rather nauseate  than vomit; for in nausea we  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 instauce 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
  * Mm. Med. Part n. Ch. xix. p. 470.
  + Keck, AbhauJlung,  und Beobacbtungen.  MedinUches Wochenblr.tt.  173:'\
No. 49. 
464
HJEMATICA.
[CL. III.-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
when an active  hemorrhage from the lungs is profuse and obstinate,
the vessels lose  their tone and  fall into a passive state.
  In h-ematemesis the blood is evacuated from the alimentary canal
at either extremity, whether 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 with 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
darker  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,
* PcrcivaPs Essays, Vol. n. p. 181. 
GE. II.-SP. I.]          SANGUINEOUS FUNCTION.             465

and suddenly,  and  without*pain,  it proceeds  from  the  kidneys;
hut 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  when
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.!
   In connexion with  the general  course of treatment already re-
commended in  the preceding  varieties, the  compound powder 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
 with 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 the proper fluid, the uterine arteries will be
 inordinately gorged ;  the regular stimulus  will be greatly augment'

               * Lib. vn. Obs. l. 24. ex Langio.
               t Hist. Mort. Uratislav. p. 58.
                                 59
VOL. II. 
466
H/EMATICA.
[CL. III.-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
 anastamosis ; 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 * 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, we 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 seve-
 ral 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
 mensti uation 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
 when 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;
 when 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 walking 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-
 bmthinate preparations, or even  pungent aliaceous sauces.   The
irritation ot piles is also a  very common cause;  and hence by some
writers 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  expe-
rienced.
  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 aperients 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 artificially to the freezing point, or may  use a cold hip-bath, 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.

            HiEMORRHAGIA ATONICA.

                    &tomc f^rmorrhagr.

ACCOMPANIED  WITH GENERAL  LAXITY OR DEBILITY ;  AND WEAK,  VASCU*
       LAR 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 thoso of the species  before us.
  When plethora is the remote cause, which it often is, it is  atonic
plethora, or plethora of debility; but whatever  has a tendency to 
468
tLEMATICA.
[CL. I1I.-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 discharg-
ed without tensive pain : though there must necessarily  be an ex-
pulsive effort; and, from the inanition hereby produced, some de-
gree 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 with semen,
sometimes instead of it, and sometimes  immediately after emission.
The individuals  have been generally persons of highly irritable
and  delicate habits;  and who 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 Ephemerides.
  There is little  pain in atonic hemorrhage  from the uterus :  and
it generally  occurs at the natural cessation of the menstrual flux, or
within a few years afterwards.   As a concomitant, hemorrhage from
this quarter  is also frequently found in a scirrhous, cancerous, or
other morbid states of  the uterus, in whatever period of life these
may occur ;  whiofi, however, they do most usually after  the age of
forty or fifty.
  Atonic hemorrhage from the anus usually takes place  spontane-
ously with little or no pain ; but commonly with varices  or conges-
tions 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 evidence 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 with 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,
however 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 with great advantage along with bitters; and, with
a few 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 we 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 with 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 here 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. CulJen, 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 dyspepsia,*
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 when 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, however 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. t. p. 111. 120. 
470
HiEMATlCA.
[CL. III.-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 hut 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.  1 recommend-
ed, however, carriage exercise,  and  an excursion to the sea-coast,
which  has been complied with, and there has been no recurrence of
the disease.
  To effect  the same intention,  I have occasionally advised cardiacs
combined  with astringents in haematemisis, where  the  discharge of
blood has  been profuse, and  has continued for some days, and  the
patient has become considerably exhausted : and  1 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 uterus, I have had  the vagina in-
jected  with  equal parts of port wine and water 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 was  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  uf  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 tota  substantia; hut 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.'"!  In  corroboration of which  Dr.
Heberden tells us that its good  effects  are by no means  so  certain

           * Vol. I. p. 31.
           t 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 world 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 tfnctura 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. Latham! 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 with
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,  ndthing pernicious exists  in  its
superacetate; in the process for which 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. ill. Ait. xui.
+ Vol. v. Art. xxr. 
472
H^MATICA.
[CL. III-OR. IV.
  It only remains to be added, that where entonic hemorrhage has
occurred so profusely, or has continued so long as to reduce the
system to an atonic state, it then becomes a disease of debility, and
is to be treated as though originating under the present species.
                     GENUS  111.


                      MARASMUS.

                        32mactatfou.

        GENERAL EXTENUATION OF THE  BODY  WITH DEBILITY.

Marasmus is a Greek term, derived from fix^xim, " maresco," " mar-
cescere reddo."  It was long ago used collectively to comprehend
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 unit-
ed 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, which, before the system falls a prey to confirmed old
age, sometimes makes its appearance  in  advanced life  without an\
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.  Eut 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 with 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 lo ; est to
 the  highest  degree.  Dr.  Pemberton,  in  a work 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  sincf 
GE# IU1            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 two cases of a  diseased state of the mesen-
teric glands? and 'a diseased or scrophulous  affection  of the breas .
In the former we shall find there is a great  emacia ion ; in the lat-
 er none at all.-ln an ulceration of the small intestines great ema-
dalion  takes place;  in scirrhus of the  rectum  none- n a disease
of the gall-bladder, which is subservient to the liver, the bulk  ot
the body is rapidly'diminished ; but in a disease of the urinary Mad-
der, which is subservient to the kidneys, scarcely  ^diminution of
bulk  is to be perceived.  In an abscess of an liver,  the body  be-
Lmes  mucreSated; but in an abscess of the  kidneys, the bulk

 16 "If  wetxamfoe 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 may be 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 m  the
 system, as well as the glands of direct supply,  may be considered
 the  liver, the pancreas, the  mesenteric  glands, perhaps  the sto-
 mach,  and the small intestines ;  and  the glands of waste are the
 kidneys, breasts, exhalent arteries, and the larger intestines.
    The first set are, in fact, the general assemblage  of the  chyhfic
  organs; and it is upon their director 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.  IT. 
 474                     HiEMATICA.           [Ch.  IH^-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
 maiccs 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 without hectic
 fever; tabes, emaciation with hectic fever;  and phthisis, emacia-
 tion and hectic fever coupled with  pulmonary flisease.   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 IN osology, will
 properly apply; as I think  there are certain diseases  of the  same
 nature,  which  sometimes  appear with, and sometimes  without
 fever."*  ' This is written in the spirit of candour that  so peculiar-
 ly 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 these 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,  1  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 in. Book i. Sect, mdcxviii. 
«E. III.-SP. I.]       SANGUINEOUS FUNCTION.              475


                         SPECIES  I.

              MARASMUS  ATROPHIA.

                           Sltroflhy.

COMPLEXION  PALE, OFTEN SQUALID :  SKIN DRY AND WRINKLED :  MUSCLES
            SHRUNK AND INELASTIC : LITTLE  OR  NO FEVER.

The specific is a Greek term deduced from x privativa, and rpip«
"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 thqs lays a foundation for {he
three following varieties:

a Inopiae.                       Blood  innutritious from  scarcity
   Athrophy of want.               or pravity of food.
3 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 carri-
ed 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 ok waste. 
476                     HEMATIC A.           [CL.IH.-0R.1V

  Now, in all these cases, wherever the sytem 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 addition-
al elaboration of nutriment; and the instinctive effort runs through
the entire chain of action to the utmost reach of the  assimilating
powers,  or those secernents with which every organ is furnished
to supply itself with 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  new 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 which commences with the digestive and  reaches  fo 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 take place  while the waste  is still continuing, emaciation  will
be a necessary consequence even in the midst of the greatest abun-
dance : and we 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.
  It is  from the one  or the other of these  sources  that we 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. III.-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 whole, we 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 bowels, 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 squallid
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;  in some cases it fails, in others it is insatiable 
478                     HJEMATICA.          [CL. 111.-011.  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 we  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 adviseable 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 what 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 to 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 docs  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 constitu-
ent 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 grow 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 coepit."*
* Nos. Med. CI. x. Ord. i. Ex. Collect. Acad. Torn. in. p. 693 
    GE. 1II.-SP. L]        SANGUINEOUS FUNCTION.             479

      In the atrophy of debility common to old age, the cellular mem-
    brane, that is the containing as well 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.   Here 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 the lacteals,  insomuch that many of our most cele-
    brated anatomists have thought, as  I have already had occasion to
    observe,* that the mesenteric  glands of old people  become oblite-
    rated ;  while Ruysch contended that mankind  pass the latter  part
    of their Jives without 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:  where upon profuse evacuations, it falls within the
    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 advisea-
    ble  in the one case  will be equally  adviseable 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-bathing
    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
HiEMATICA.
[CL. III.-OR. IV.
                         SPECIES  II.

          MARASMUS  CLIMACTERICUS.

         29ecag of fiature.  <£ltmacterfc  Btscasr.

 general decline of bulk and strength, with occasional renovation,
      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 which as 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 (*A<^«|), which signifies a gradation, they de-
 nominated them climacterics.   They begin with the seventh year,
 which forms the first climateric; 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  we have no concern at present; and shall hence proceed to
 that which 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. 1II.-SP. II.]
SANGUINEOUS FUNCTION.
481
•   author  has  seen persons who have  been deaf for twenty  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 ot
    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.!  But I  have  occasionally seen  several of these  singu-
     larities, and especially the renewal 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, we sometimes  perceive  as sudden and extraor-
     dinary a decline.  We  behold a man apparently  in  good health,
     without any  perceptible  cause, abruptly sinking  into  a general
     decay.  His strength, his spirits, his appetite, his sleep fail equally;
     his flesh falls away;  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 application
     of which we 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 powers  or even  lost  organs  to
     which 1 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
     decline however is a real  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 which,  no doubt, it is influenced, has emphatically denominated
     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.
+ Eph. Nat. Cur. passim.
          fil 
182
HLEMATICA.
[CL. III.-OR. IV.
 assimilating secernents ;  that these form the  ends  of the  chain ;
 that a powerful 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 parenchymatous
 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 complains 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
 Halford,  " 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 process  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  acknowledges  that he  has felt pains in his head  aud 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 par»ts  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. III.-SP. II.]      SANGUINEOUS FUNCTION.              483

  Such is the ordinary course of this disorder in its simplest form
when  it  proves fatal;  and  the  powers  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
who 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,
oris influenced by a gouty or other morbid diathesis, the  symptoms
will assume  a  mixed character, and the  disease be greatly aggra-
vated.  It is these accidents indeed that for the  most part constitute
the exciting cause,  as  well  as  the most  fearful auxiliary  of  the
disease ;  for, without such, it is highly probable that the  predispo-
sition might remain  dormant; and that many a patient who falls  a
sacrifice  to  it would  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 we  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.   1 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.
  1 have at other  times seen the same effect produced  as  clearly
and decidedly, though with a much tardier step, and unaccompanied 
484                     HiEMATICA.           [CL.  III.-OR. IV.

with any sudden shock.   1 attended not long since a lady in Edge--
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  whole 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 weeks
after  her decease, 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  dimi-
nishing, and his nights restless,  with  little  fever,  and altogether
without  any manifest  local  disorder.   The  emaciation  with its
accompanying evils,  nevertheless increased,  the general  disease
became confirmed, and in about five months  he fell a sacrifice  to it.
  Occasionally, however,  where  the climacteric temperament, if 1
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 was not habitual, the first apparent cause of it.   A fall, which
did not appear of consequence at  the moment, and which would 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
which the following  case will afford a very striking example, and
show  in the clearest  colours the general want of  tone which under
this morbid  influence prevails throughout the system.
  Most pf my readers of this metropolis have beard 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 with  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 unwearied efforts to patronise merit in
whatever rank it was to be found, ought not to have  beeil withheld
from  the world.   In November  1816  this  gentleman, then in his
sixty-first year, and blessed with one of the firmest and most vigorous
constitutions that 1 have ever known, applied to me for an erysipe-
latous affection of the-face.  It was troublesome, and for nearly a
fortnight accompanied with a slight fever, and  a  good deal of irri-
tation.  It  subsided  at length, but  left a degree of debility which
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 ail the strength and elasticity he
formerly enjoyed.  Insensibly, and without any ostensible cause, he
became  emaciated,  walked from Russel-Square  to  the East India
House with less freedom than usual, and found his earriage 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.  H.]      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, however, evinced no sweetness, and both these
symptoms rapidly  disappeared  under the  medical  treatment laid
down for him.   The general waste,  and debility,  however,  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  were
now engaged  in  consultation  with  myself,  as was  Dr.  Hooper
afterwards,  it was a doubtful question, what 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 view of the
case there was reason for congratulation.  But it was 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  advautage  followed: it was evident  there was 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  wound was of subordinate
importance, and would follow  the fortune of the  general frame.
The issue was still doubtful, for the  constitution resisted pertina-
ciously,  though  upon the whole the  disorder  was  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 was 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 wished for
or conceived.   Unfortunately its progress, though retarded  by the
arms of medicine,  was retarded alone.  One  of the last recommen- 
486
HjEMATICA.          [cl. III.-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 fiitigue 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 warm and bitter roots or resins, as
rhubarb,  guiacum, 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  1 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  which 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. III.]    SANGUINEOUS  FUNCTION.               487
                       SPECIES  III.


                 MARASMUS  TABES.

                           Bttlint.

KENERAL  LANGUOR ;  DEPRESSION OF STRENGTH, AND,  MOSTLY,  OF SPI-
                      RITS ;  HECTIC  FEVER.

Tabes is a Latin term of doubtful origin.  The lexicographers de-
rive it from the Greek th*«, kt macero," varied in the Doric dialect
to rxxa,—whence Scaliger makes a compound of raxtQtos, " 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 Hebrew ^tfjl  fab), 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 well 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 scrophufous taint;
or an irritation  produced by  excess in  libidinous indulgences:  thus
laying a ground-work for the  four following varieties :

      * Purulenta.              Purulent decline.
      £ 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 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.  EHin. 1732. Lentilius, Jatromnemata.
B. 384.  Sttitta.  17V2. 8vn. 
488
HiEMATICA.
[CL. 1IE.-OR. IV.
this supposition is altogether  gratuitous :  and where 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, whether 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 with  which the blood is here-
by contaminated, is alone sufficient to excite  and maintain the  hec-
tic ; as the hectic is alone  sufficient  to wear away the strength and
substance  of the system, and produces the waste.  It is a disease, as
Scheffler  has observed, chiefly common to miners and mineralo-
gists :* 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 regene-
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  intb developement 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 often or twelve years, and
ifitdonot  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. 
 UE. III.-SP. III.]      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 weakly state;  most commonly upon the me-
 sentery, and to this quarter it  often  confines itself; insomuch that
 u 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 mesente-
 ry, through which 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 ;! so rare, that Mr. Cruikshank affirms he never saw such a
 stagnation on the  dissection of any mysenteric case whatever.   And
 that a scropulous  enlargement of the glands of the mesentery  does
 not 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.' in. Book i. {-mdcvi.
     t Vol. i. p. 2S2. Clr j. Ord. n. Parabysma Mesenterkum.
  VOL. n.                    G2 
490                       FLEMATICA.           [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 powers  that constitute the opposite end  of
the chain of nutrient organs, and which from  their morbid excite-
ment produce a morbid waste, and  demand a larger  supply  than
they receive.   As worms  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.!  In the  strumous  enlargements are  occasionally
found  calcareous concretions,  such as often appear  in the joints
when 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 $01212
NOTlAS,||  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-
row, 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
 without 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 driness of the tongue.
* Chesneau, Lib. v. Obs. 27.
t Journ. de Medicine, 1790. Sept. N. I.
X Douin, Journ. des S^avans, 1690.—Monro, Med. Trans, n. Art. 18.
§ Histoire de l'Academie des Sciences, &c. 1684.
|| Ilift to svfio; FlctOow, Opp. p. 539. as also fcleg/ Nwrur, II. Opp. p. 479.- 
GE. II1.-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- t
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 which has a singular power 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 must be 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 or females, have a
close and striking sympathy with the  organ of the brain; and the
fluid they secrete with the nervous fluid.  Whence Willis  conceiv-
ed that the fluids of both organs are the same, and hence expressly
accounts for the debility.!  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 Pliys. Part. in. B. i. i mdcx.
t Pharm. RationalU de Medicament, Operat. Pars. 2. 1675. 
492                     H^EMATICA.           [CL. Ill.-OR. IV.
 haunt the worn-out debauchee, and especially the self-abuser, from
 involuntary emissions of a seminal fluid however dilute and spirit-
 less, in connection 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, which 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 which 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 while 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 would 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 fr»m
 a use of the alkalies, which,  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 we 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 with that for most of the species of parabysma, or visceral
 turgescence,  already laid down under their  respective heads and


Do^alirGiSuy P°n ^ TabCS D°r8aliS' LOnd* ""-BwwW, «»• de Tab.' 
GE. III.—SP. III.]       SANGUINEOUS FUNCTION.              493

particularly with that for mesenteric parabysma, to  which the rea-
der  may turn.*
   In the treatment of tabes dorsalis, or decline from intemperate in-
dulgence, our attention must be  directed to the mind as well 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
 nights 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 water 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. 1. Ord. n.
  + See Wichmann, De  Pollutions diurna, frequentiori, sed rarius observata, Ta-
bescentiae causa. Goett. 1782. 
494
HJEMATICA.
[CL. III.-OR. 1\.
                        SPECIES  IV.

                MARASMUS PHTHISIS.

                        QEonaumption.

COUCH :  TAIN OR  UNEASINESS  IN  THE CHEST,  CHIEFLY ON  DECUMB1TURE :
           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 incipiens, 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 when it  appears to produce consumption it  has itself been oc-
casioned by an incipient obstruction of a different kind."!  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  oi
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.
t Treatise on Consumptive Diseases, p. 45.
X Sur les Maladies Veneriennes, la Rage, et la Phthisic, &c. 12 Bord. 1733, 
GE. II1.-SP. IV.]
SANGUINEOUS FUNCTION.
495
from a close  and practical  attention to the disease,  and are as fol-
low :
x 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 mucus, rarely mixed
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 the apostematous 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 few 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, wheylike  sanies, sometimes
tinged with  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 isintroduc-
ed as a genus, and consequently the varieties now offered as so many
species; yet  as the tubercular may run into the apostematous varie-
ty, and the catarrhal  into both, according to  the peculiarity of the
constitution,  and  other concurrent  circumstances, and more especi-
ally as a common cause may produce all of them in different idiosyn-
cracies, the present subdivision will perhaps be found the  most cor-
rect.
  Dr.  Wilson Philip,  has formed another variety (with him species)
of consumption,  to which he has  given the  name  of  Dyspeptic
Phthisis, and which  he  supposes to be produced by a previously
diseased state of the  digestive organs in which the lungs ultimately
participate.  u 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  what 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't
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, we find  the affection of the lungs the
primary disease: but,  in these the case  does not assume  the form 
 496                    HiEMATICA.            [CL. II1.-0R. 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 idiopathic 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;! of most of which we can know no-
 thing till the death of  the patient;  Portal fourteen,]: the  first two
 of which, the scrophulous and plethoric,  are  peculiarly entitled to
 attention, while the rest are drawn from  other diseases  with which
it is  often  complicated,  or bf which it is a sequel.   In  Morton and
 Sauvages  the divisions and subdivisions are almost innumerable.
 The Greek pathologists are not chargeable with 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
 H^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 as 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
 who suffers from it in its  genuine form.1T  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. vii. p. 499.
  t Recherches sur la Phthisie pulmonaire. Par. 1810.
  X Observations sur la Nature etla Traitement de la Phthisie pulmonaire, 2 torn.
 3vo. Paris, 1809.
  j Morb. Chron. i. 10.                                                  ^
  || On Consumptive Diseases, Ch. ill. p. 20.
  *  Recherches sur la  Phthisic pulmonaire. Par. 1810. 
QE. III.—SP. IV.]       SANGUINEOUS FUNCTIfN.             497

that Of thirty-five, though it occasionally anticipates  the  first, and
overpasses the second, of these limits; the mean term of its proving
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  will be
noticed presently.   The exciting or occasional causes are very nume-
rous,  as mechanical irritation of the lungs 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 cutaneous disease  that has
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, when 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,!  when  at remote distance
from  one's friends and country.
  Examples of consumption from a mechanical  irritation of the
lungs are peculiarly numerous, and they furnish cases of every va-
riety of the disease according to the habit or idiosyncracy,  though
the apostematous is less frequent than the rest.  So common is th:s
complaint  among  persons  employed in dry-grinding,  or pointing
needles in needle-manufactories,  that Dr  Johnstone of Worcester
informs us they seldom live to be forty, from  the accumulation  of
the dust of the grind-stones in the air-cells of the  lungs, and the ir-
ritation and suppuration which follows.J   It appears to be little less
common among  knife  and scythe-grinders; whence,  according  to
Dr. Simmons, the  disease thus originating  is called the grinders'
rot,§  and  Wepfer gives an account of its proving  endemic at 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 dis-
colours, 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. Lontl.
1808.
  t  R. Hamilton, in Duncan's Med. Com. xi. p. 343.
  X  Mem. Med. Soc. v. 1799. p. 89.
 i Pi act. Observ. on the Treatment of Consumptions, 8vo. 1780.
  vol. ii.               63 
498              4     HiEMATIUA.            [CL. 1H.-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 even 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
when he was fortunate enough to bring up the piece of  bone spon-
taneously, in consequence of which he  recovered, though for the
preceding four years he had laboured under an haemoptysis.^   Mr.
Holman describes a similar case that had run on for fifteen years,
accompanied with cough, haemoptysis,  and hectic  diarrhoea;  and
which 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 wind-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 known 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 Ima-
ginaire.1T
   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.
  t Trans,  of Soc. for the Improvement of Med. and Chir. Knowledge, Vol. I.
252.
  X Sedill. Journ. Gen. Med. xxxiv. p. 13. 1809.
  } Lond. Med. Journ. vn. p. 120.
  || On Consumptive Diseases, p. 264.
  * Van Swieten, Aph. iv. $ 1201. p. 4^. 
«E. III.-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 i nstance
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;! but whether this would 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.J  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  bv
swallowing a nail two inches long, which remained in  the stomach
fifteen months, and was then thrown up,  and succeeded by a recov-
ery of health.§
   Rapid growth 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 al-
so is a remark that  has been made by Bennet,1T though  I  do not
know that it has been supported by 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.
t Vestibulum Tabidoruin, 8vo. 1654. Leyd.
X De Morb. Thoracis. Lib. n. Ep. Anat. xxi. 43.
5 Vol. i.  1796.
|| Sedill. Journ. Gen. Med.  xx. p. 255.
^ Tabid. Theatr. p. 99. 
500
HEMATIC A.          [CL. III.-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  ma-
ny 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 was hot and dry, the duty very severe ; and the sail-
ors, wet with sweat, 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- 'which are most  subject to changes of
temperature.  In Great Britain,  it is calculated that this  disease
carries off usualfy  about  one-fourth  of  its inhabitants;  at Paris,
about one-fifth ;  and at Vienna, one-sixth : while 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 whether hotter or colder.!  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 water 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-wells are by no
means deserving of  the  credit  ascribed to  them; as, during a
residence of some time at and near these  wells, 1 cannot  charge my
memory with a single instance where any person, labouring  under a
confirmed phthisis, experienced much relief from their use alone."1f
   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  succesion, 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. m. p. 325.
  t W'oolcombe (Dr. W.) Remarks on the frequency aiid fatality of Diseases, 8vo.
Lond. 1808.—Southey (Dr. H. H.) Observations on Pulmonary Consumption, 8vo.
Lond. 1814.
  X Young ut supra, p. 42.
  &  Manual of Health, &c. 12mo. Lond. 1806.
  1 Practice of Physic, p. 508, sixth edit. 
OE. HI.-SF. 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, Darwin, and
most modern writers.
  1 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.!   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,!  and 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.   It is a remark
far better supported  that the teeth are peculiarly clear,  and the
eyes peculiarly bright;  and that both become more  so when 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.
t Medical Inquiries and Observations, &c.  Vol. I. 8vo.  Phil. 1789.
X Epidem. v. p. 1142.
i Chion. Dis. i. 10. 12.
|| CI. i. Ord. i. Vol. i. p. 33, 
502                      HA.MATICA.          [CL. 11I.-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 1o 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 towards 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 now deciiedly established ;  the  cough  increases
in frequency, and from  being dry is accompanied  with a purulent
mucus, varying, according to the peculiar modification of the disease,
from a watery whey-like sanies occasionally tinged  with 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 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 assumed1 its full character;
the patient  can lie with comfort only on 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 now 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-whife ;  " 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 whole
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. III.-SP.  IV.]      SANGUINEOUS  FUNCTION.              503

  The third stage  is  melancholy and  distressing, but usually of
short duration.  It  commences with  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, with 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 greatej.   " A few
days before the patient's death, he is frequently unabh/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 or 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
estuation 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
swallowed 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 was the progress of the disease in the
* Voung, On Consumptive Diseases, p. 28. 
f>04
HJEMATICA.
[CL. III.-OR. IV.
case of the Duchess de Pienne, that M. Portal informs us she died in
ten or twelve 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 hemop-
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 whole 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, whfsh 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 circumscrib-
ed 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.!  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 when the disease has fol-
lowed rapidly upon  peripneumony, or taken place in persons of ro-
bust habits or entonic plethora.  And,  where  the  catarrhal symp-
toms have been striking, and, in the  increasing hoarseness and free
discharge of muculent pus, have evinced expensive 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. n. vii.
  t 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 Ian
guage  of the same writer to leave u a vacant space" in the chest;
or, in that of M. Bayle, to be shrivelled  into leather.  On this  ao*
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 with  a drop  of this fluid is ren-
dered soapy, while neither blood nor mucus is  affected by it.!   Mr.
Charles Darwin

           Heu miserande puer! si qua 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 powerfut 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  i*, 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 way 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 v/ill 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  S.-puIchr. Lib.  I. Sect. n.  Obs.  167.—Paiom,  Raccolti d'Opuscoli
scientifici xlvi. p. 275.
  t See Apostema commune of the present Volume, p. 169.
   vol. ii.                     64 
:iO»i
HiEMATICA.
[CL. III.-OR. IV.
 thing he 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 :  while 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 with 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 i*
 sometimes accompanied  with a  hectic  or even  a typhous fever.
 And hence  his  principal  remedies were  salivation,  or  bleeding
 which he sometimes prescribed fifteen times in six weeks, emetics,
 nitre in large  doses, a  milk and vegetable diet, walking 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 with va-
 riable success upon a large  scale.  But  a  practice  of an  opposite
 kind equally bold, and which soon became equally popular, was pro-
 posed at the same time by M. Salvadori of Trent.f   Consumption, in
 the view of 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 prescribed soup,
meat, wine,  porter, brandy and water, eggs,  oysters,  with proper
condiments.   Swinging was interposed twice a-day; and horse-ex-
cise was to complete the  cure.§
* Journ. de Med. 1777.
t Med. Inquir. and Observ. i. 8vo. Phil. 1789.  n. 1793.  v. 1802.
X Del Morbo Tisico, 2 Vol. 3vo. Trent. 1787.
i Lond. Med. Journ. ix. 1788. 
GE. I1I.-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 was 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:! Dr Barton affirms he  has never
known but one case cured by it, though others may have been pal-
liated :\  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.
 t Essay on the causes,'early signs, and prevention of Pulmonary Consumption,
1799.
 X Collections for a Materia Medica, 8vo. Philadel. 1798.
 J Med. Diet, in verb. Phthisis, Vol. II. p. 401.
   Epanetus Hcctica. Vol. n. p. 115 
508                     HiEMATlCA.           [CL. III.-OR. IV.

midst of all the contrariety of practice we have just noticed, are the
following:—
     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 the lungs or bronchia?, such as, in the former case, fixed
pain and weight in the chest, increased by lying 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 an  approach towards  a cauma, constituting the plethoric
species of M. Portal, and the  inflammatory of Dr. Rush, there  can
be no question that  our object in both these  cases should be to di-
minish the vascular action by every  mean in our power.  Copious
bleeding by venesection should be had recourse  to with all  speed:
and though we  shall seldom be called upon so closely to follow the
steps of Dr. Dover as to repeat the operation fifty times in  succes-
sion* before we 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-
chia? the former, of which three or  four grains may be given three
or four times a-day,  and will  often prove expectorant, and unload
the muscous pellicles of the air-cells.   The  bowels 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 we 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 i.n  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  flow of
genuine  mucus, like that of genuine pus, depends upon only  a small
^Ancient Physician's Legacy to his Country, 8vo. Lond. 
GE. III.-SP. IV.]       SANGUINEOUS  FUNCTION.            50VJ

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:  Jiut 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 sweat 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 insiduous; 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
two 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.
         t See Epanetus  Heetica. Vol. u.  p. 115. 
510
H/EMATICA.
[CL. 1II.-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.!
  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
disease5, it was of no  service in preventing phthisis, and in some
cases seemed to hurry it on."j
  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-
nioniated copper; and muriate of barytes.   And with a like want of
success, he tells us in addition, were employed the vegetable narco-     t
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.
t Medicina Nautica. Vol. III. p. 359.
X Pract of Phys. Vol. n. Sect, dccccvii.
|| Med. Trans. Vol. iv. p. 129.
* Pract. of Pbys. Vol. II. Sect. DC cct vj i 
UE. I1I.-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 me-
tallic 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 in 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 where 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 which it 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 which we can avail ourselves.
  In some instances, however, it does allow such interval, and espe-
cially  where  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 suc-
ceeded 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
writers, 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. u. p. 115. 
512
ILEMATICA.          [CL. II1.-0R. 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 power  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 too  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. 1V.1     SANGUINEOUS  FUNCTION.               513

been in administering it too freely, as in doses of fifteen grains or a
scruple; in which 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  with
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 with 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  somewhat  less grateful
than the native, seem  to be more effectual as tonics.   The acetous
acid v\as employed  freely by Galen, diluted with water,  who re-
garded it as the best refrigerant we 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 was  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 was 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 fctate
of convalescence  bordering on perfect health ; and, on his  return to
France,  pursued  the same  plan, with the  exception  of the ironj
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 hi9
cases was  of a very unpromising aspect; and consisted of a voung
gentleman, seventeen years of age, whose elder brother  had died
ef phthisis  two years before.  The cough,  which,  in  the morning
               * Med. Trans. Vol. V. Art. xvin
VOL.  II.           6t> 
o 14
H/EMATICA.
[CL. I1I.-OR. IV.
was very considerable, was accompanied with expectoration some-
times streaked with blood; a confirmed hectic  preyed  upon him
and the night sweat was so profuse that his hair was drenched with
it.  « Mv 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,  which was also tried, did not seem to have any  advantage.
The acetous was usually given in half ounce doses with an ounce
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 well 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 itis
also an active  astringent is known 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, when  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 powers, 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 contents of
the frame,  and give breadth as well as firmness to the muscles.   In
haemoptysis, I have  carried the use  of acetous  acid much farther
than was prescribed  by Dr. Roberts,  and with manifest and unmixed
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 agarics! given in the torm
of lozenges, and the superacetate of lead ;\ but they have far more
generally been employed without success or  with more mischief
than advantage.
   The  most direct means  of supporting  the system  would  be by

   * Med. Trans, ut supra.
  t De Haen, Rat. Med. Tom. n. 567.  Dufresnoy, in Corvisart, Journ. Med.
Cent. vn. 531. 1804.
  X Ewell in S.'-dile. Journ. Gen. Med. xliv.  Hildebrand, id. xxxvi. 
GE. UI.-SP. IV.]
SANGUINEOUS FUNCTION.
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 he 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 intermitent
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.  •k 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 vomica? 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  occasionably 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 adviseable,  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  expers 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 mo«t cautious phvsicians. from the time of the Greeks 
die
1LBMATICA.
[CL. III.-OR. IV,
to our own  day,  have concurred in recommending food in small
quantity as well as of the lightest materials.  It is not merely the
stomach and its colhtitious organs that  are hereby  put at rest, but
the circulating system, the assimilating powers, the  brain, and the
intestines.  And hence there  was 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 afterwards, 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 up-
on a diet of this kind, in conjunction with  temperate air and exer-
cise, the Greek; physicians placed their only hopes of a cure. Wheth-
er 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.   Galen  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.!  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
nvtk  moct sugar and least butter and caseous matter  next to mare's,
w.th most cream next to sheep's.J  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-
sophyHum.   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, which 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.
t Co ■iment. Tom. iv. Sect. 1211. edit. Lu^d. Bat. 1764.
+ See CrellV Chemische Annales, $ vm. p. 138. 1794. 
6E. HI.—SP. IV.]     SANGUINEOUS  FUNCTION-
517
The ordinary form consists in boiling eighteen contused snails with
an ounce of hartshorn-shavings, of eryngo-root and pearl-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  aourishmmt
it adds a tonic power 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 pyxidatus, 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 pidmonarius,  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, however, 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 own chamber, or set of cham-
bers, by keeping the thermometer at from 60° to 65°  of L< arenheit,
 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 be may support  the requisite
temperature, he cannot conveniently obtain a sufficient  change of
* Med. Trans. Vol. n. p. 341.
r Hist, de la Societe Royale dp Medicine, n. 295. 
518                     HjEMATICA.            [cl. iii.-or. IV.

uir, nor so well avail himself of the various exercises that might be
useful to him, as if he  were at liberty to go abroad.
  Hence a change of abode has been recommended in all  ages to
those whose 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-western 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.!   Nice and Na-
ples are said to  be  equally unfriendly  from the neighbourhood of
mountains;  and Dr.JSouthey'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.6
  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 conveniences,  to  which the patient has been  accustomed at
  Sir G. Blane, Observations on the Diseases of Seamen, 3vo. 1785.
i  Account of the effects of Swinging in pulmonary Consumption, &c. 8vo. 1787.
I  Observations on Pulmonary Consumption, 8vo. 1814.
i  Observations sur la nature et la traitemcnt de la Phthisie milmonaire, n  n 
GE. III.-SP. IV.]      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 otherwise form an excellent asylum 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 town is built in a deep ravine opening towards
the  north-east, that lies  between them, and  the new town 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 suffocative 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,
when 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,  who feel incon-
venience from a residence  on the sea-side, are  almost instantly re-
lieved by sailing at a few miles distance 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: thr 
520
HEMATIC A.          [CL. IU.-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, who
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
ths beginning;  and to such cases of consumption Desault judicious-
ly limits it.   In the present day it has been revived by Mr.  Stewart
uider a variety of ingenious modifications,  and appears in many
eu.-^s to have afforded relief: but the constitutions of mankind  must
strm^elv have altered since the days of Sydenham, if the  severity
of horse exercise could as  that period have been employed as a
specific remedy in consumptions of  every kind. Stoll did  not find
it -o 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 is surely as if he were in a  pleurisy.  And Stoerck died con-
sumptive though in the habit of riding, killed by an haemoptysis ap-
parently produced by this exercise.J
  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  attemp-
ted  by fumigations, medicated airs, and expectorants.
  Bennet was strongly attached to  the first of  these, and thought
they proved peculiarly detergent, and enabled the  patient to throw
up a more  laudable  discharge with increased facility.   He some-
times employed aromatic herbs which were immersed in hot water,
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 dependance  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.
t Nat. Med. i.
t Quarin, pp. 168, 103 
 6E. I1I.-9P. IV.]     SANGUINEOUS  FUNCTION.

 tbinate 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  where 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 will 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, may be taken  internally with  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, when 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 gass 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 with  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. I v. p. 83. 1790.
VOL. II.                  6G
521 
r)22                   -HjEMATICA.             [CL. IH.-OR. IV.

in the Journal de Medicine, relates a case of confirmed consumption
r.nred by an habitual residence in a coal-mine;* and expressly states
that the matter expectorated  soon began to assume a more healthy
appearance, and was excreted more  freely.  It is, in like manner,
a common remark that the miners in Cornwall  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, we are to ascribe the
benefit which Bergius found consumptive patients derive from a re-
sidence  in cow-houses,! and which  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 purpo=e; 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 few.
  Where the irritation is considerable, and  accompanied with much
increase cf 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 it is 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  bronchiae  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 i? carried to the  rectum, and the skin sometimes, with little  alte-
ration ;  and  hence gently stimulates  both  extremities, loosens the
boweK and excites a pleasing diapnoe on the surface.  It is in this
way 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 ;t with yolk of egg ; and it  has maintained its character to
the present day.  In the tubercular, or scrophulous variety,  as it is

       * Jnu.n. Med. xvm. 59.
       + Southey, Observations on Pulmonary Consumption, 8vo. 1814.
       X Ni'up Schwed. Abhandl.  1782. P. in. p. 298.
       V Vol. i. pp. 352. 30-.\ 
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.!
  The vulnerary balsams an.l resins, however, 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 dimi-
nish 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 in-
tervals.
   Setons, issues, and caustics, however, where the constitution is not
very delicate, nor the  habit very irritable, have  proved  far more
powerful revellent^,  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.
t Medicina Nautica, Vol. in. p. 325. 8vo. Lond. 1814.
X Therapeutica, Lond. 1758.
}  Practical Observations on the Treatment of Consumptions, Lond. 1780.
J|  Radical Cure for a recent Catnrrhous Cough, p. 7S. Ovo.   Loud. 17TV 
524                     HJEMATICA.           [CI« HI.-OR. IV.

issues, which he placed in the groins and bams, under the arms, and
between the *ho,ild<-rS and kept sweet by peas of orris  root;  and
asserts that he found the use of these highly beneficial.  Yet scions
are said by those who have employed them to be still more service-
able than issues.                             , .       . ,     ,
  The obvious intention is to produce a  revulsion; and hence by
transferring the morbid action  to a part of less importance, to allow
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
which 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-twenty times in a night, and even thi* was not
sufficient.  The paroxysm proved critical; and the disease was 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  on the air, or on  the nerves of the sick,  that
some who  were 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.!
  Bennet relates a case of consumption which  was suspended for
two days in all its  symptoms,  except  the  emaciation, by a severe
tooth-ache.J  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 numerous 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  she conceive again
shortly afterwards, she renews it: and there have been instances,
in which from a rapid succession of pregnancies,  the suspension has

  * Kecherches sur la Phthisie, &c.  ut supra.
  t Observations on the Diseases of  Seamen, 8vo. Lond. 1785.
  X Vestibul. Tabid, ut supra.
  4  Recueil d'Observations de Medicine, Sic. Part n. 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 well known to have
a frequent  influence upon another, and consumption is found to be
thus influenced by various affections, it is a question well worth in-
quiring into whether there be any malady of less importance, which,
like cow-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 finding 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; while  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 worth 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.!
                     GENUS  IV!

                         STRUMA.

                         Sktxopnxiiz.

indolent, glandular tumours, chiefly  in  the  neck ;  suppurating
  slowly, and  imperfectly, and  healing with 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

  *  Trans. Medico-chir. Soc. Vol. in. p. 471.
  t  Inquiry into the Influence of Situation on Pulmonary Consumption.  By J. G.
Mansford, &c. 8vo. 1818. 
 526                     HJEMATICA.           [CL. III.-OR. 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,
 which is therefore selected on the present occasion.   It is probably
 derived from rr^aftx,  " congestion," or " coacervation," as of straw
 in a litter, feathers in a bed, or tumours in the body;  in which last
 sense  Cicero  elegantly employs the  term as  a metaphor in the
 phrase "struma  civitatis," "the  scrophula  or  king's-evil of the
 state."  The medical dictionaries and glossaries concur in deriving
 struma from the Latin struo, but the terminating syllable of the noun
 should rather prove it to issue from a Greek source.
  Dr. Stoll endeavoured to make a distinction  between scrophula
 and struma,* by regarding the one as a local, and the other as a con-
 stitutional and hereditary disease;  but  although he has been follow-
 ed by a few writers, as  well  in  our own country as on the conti-
 nent, it is a  distinction  which has  been  generally relinquished as
 neither useful nor founded  in fact
  Other animals are subject to this disease besides man.   It  is, as
 already observed, from the frequency of its appearance among swine
 that  the Greek name, as well as the more recent one of scrophula,
 is derived.  Among  horses we meet with it at least as often, when
it is  called  farcy;  under  which modification it is  propagable by
trarisfusion of blood  from  the diseased   horse,  not only to  other
horses, but  to  asses   also,  as has  been lately proved  by Professor
Coleman,  at the  Veterinary Institution.   Sauvages, who has many
species under the generic character, has  two  for  the forms  now
referred to.  The porcine species he denominates scrophula  Cha-
 lasis, and the equine s. Farcimen.
  As it is not  the intention of the present work to notice the dis-
 eases of other animals, otherwise than by an occasional and  inci-
 dental glance, we shall proceed to a contemplation of the  present
genus under the single species of

          1. struma  vulgaris.              king's evil.

  The strumous and mesenteric decline, in the present classification
atrophia strumosa, is often introduced as a second species : but though
nearly allied to the present genus, it  has so much closer a connexion
with all the  subdivisions of the genus marasmus, and especially  with
 that  of atrophia that  the former is evidently its  proper place ; and
we have accordingly treated of it under that genus.  In Dr. Cullen's
 Synopsis, it is arranged under the  genus scrophula ; and in defe-
 rence  to his authority it was allotted a  like position in  the first
 edition of the Nosology of the present writer :  but in the subsequent
editions it will be found transferred to  the position before us.
* Praelect. p. 30. 
GF. IV.-SP. I.]       SANGUINEOUS FUNCTION.              O*-'


                         SPECIES  I.

                STRUMA VULGARIS.

                        King's  Etofl.

tumours  confined  to the external conglobate glands;  PEA-SIZED7
  or chesnut-sized ;  appearing in  infancy or youth ;  SUBSIDING ON
  mature age ; hereditary.

Scrophula though  not a  contagious disease is unquestionably here-
ditary :*  and hence  very generally  dependent  upon a peculiar
diathesis.  Yet, like  many other hereditary diseases, it is  also occa-
sionally  generated as a  primary affection, without any hereditary
taint that can be discovered.   I  have  at this moment a gentleman
under my care who has been greatly afflicted with it for many years,
and is now chiefly labouring under its  sequelae : for the sores, which
are in different glands and joints, and  some of which have affected
the bones, are healing: yet of eight brothers and sisters who have
reached the  middle  of life, he is the only one who has discovered
any  tendency to such complaint, nor is  it to be traced through any
part of the family  lineage as far as it can be ascended.
   When it occurs  as a primary or ingenerated affection it is by no
means always  limited to any particular temperament or habit  of
body.  The individual just  noticed is of moderate stature, brown
complexion, dark brown hair, and ruddy face :  and I  am still occa-
sionally attending a  lady who  has long been subject to the same
complaint without any  trace  of hereditary predisposition, of  a
sallow countenance,  dark eyes and hair, and of rather tall and
slender make.  But where scrophula appears hereditary, and espe-
cially where  it does not show itself  very early,  it is often  accom-
panied  with  a peculiar  constitution.   " It most  commonly,"  says
Dr.  Cullen, " affects children of soft and flaccid flesh  ; of fair hair,
and  blue eyes; smooth skins, and rosy cheeks; and such children
have frequently a  tumid upper lip, with a chop in the middle of it;
and this  tumour is often considerable  and extended to the columna
nasi, and lower part  of the nostrils."  And it is a  farther remark of
Dr. Cullen, but which I have not found to hold very generally, that,
where it takes place in children whose  parents have given no signs
of it, the latter have nevertheless evinced  much of  the habit and
constitution by which the disease is ordinarily characterized.
   From  all this we have a clear proof that  king's evil is a disease
of debility, operating by a specific influence on the circulating, and
  *  Kirkland, On the Present State of Surgery, Vol. II.  Kortum, Comment, de
Vitio Scrophuloso. Lenigo, 1789.
  Baumes, sur le Virus Scrophulciix, Sic. 
528
H&MATICA.
[CL. III.-OR. IV.
particularly on the lymphatic system.*  Whether thi* influence is
the  result* of a specific matter is by no means so clear; however
common the  opinion.   It is also a general  belief that this specific
matter is from the first  a specific  irritant or acrimony.   But this at
least is a mistake : for the  disease is accompanied throughout with
diminished, instead of  with increased irritability ;!  and  hence  the
power producing it must be of a sedative rather than of an exciting
or actuating quality.  And  it is in this diminution of irritability that
scrophula differs from all  other  atonic  diseases, since the debility
and the irritability generally augment in like proportion, and main-
tain  an equal march.
  Early life is peculiarly characterized by an abundance of albumen,
as its maturity is by an  abundance of fibrin.  Dr. Parr ascribes  the
scrophulous diathesis to a redundancy  of  albumen  at this  period,
together with an excess of oxygene and a deficiency of azote,  evi-
denced  by  the florid  hue of the  countenance.  By  this  hypothesis
he obtains  a  sort of lentor in the circulating system ; and accounts
for the  origin  of scrophulous tumours  by arguing  that, since  the
mobility of the lymphatic system  is peculiarly affected and diminish-
ed,  the viscid fluids will be most disposed to stagnate  there,  and
particularly in  the  lymphatic glands;  as they must  necessarily
stagnate most where the impelling power is least.
  Be the proximate  cause, however, what it may, as the remote
cause is of a debilitating kind, we can readily see what are likely to
prove occasional  and  co-operative causes ; or those calculated to
call the remote cause into a state of activity.  They must consist of
every thing that directly lowers and reduces the tone of the living
fibre, and  puts the system out  of that  state of firm and vigorous
elasticity which  is the best prophylactic  against  scrophula,  and
keeps  the  scrophulous  diathesis most  effectually  in   a  state  of
subjection.   And hence we find the common  debilitating powers of
cold, damp, meagre or  unwholesome food, want of cleanliness,  and
a close  and  suffocating  atmosphere,  the most  usual  incidental
sources of scrophula.
  But for these, a scrophulous predisposition might remain dormant
in the constitution through the whole of life ; and descend  to,  and
disorder the next generation, without having in the least disturbed
the  present.    But the  moment  any  of these occasional  causes
become adjuncts with the  scrophulous diathesis, scrophula,  rather
than any other disease they are  also calculated to promote,  will
make its appearance, and commence  its ravage.   And  hence  the
frequency of this disease in  large manufacturing towns, and in higher
and colder  latitudes than 45°.
  For the same reason, the disease has,  at  times, been  called into
activity by local injuries, the depressing influence of severe grief,
on  a sudden reverse of worldly prosperity.  It is  also  sometime?
* Gain, Krai.ken geschichten. p. 121.
t Richter, Chir. Bibl. Band. vm. p. 501. 
GE. IV.-9P. I.]
SANGUINEOUS FUNCTION.
529
joined with, or follows rickets ;  and is frequently a sequel of small-
pox, yaws, and several obstinate cutaneous affections.
  But though scrophula usually commences in the lymphatic glands
it often extends beyond them:  as  gout, that ordinarily shows itself
at first in the small joints, and rheumatism in the large joints, spread
not unfrequently to the  membranes  and the muscles.  I have said
that under the influence of the scrophulous diathesis the  circulating
system is weakened generally; and  hence also we frequently find
the eyes, the mucous glands of the  nose, the tonsils, and even the
joints and bones successively yielding to its influence.
  The disease  for the  most part shows  itself early in life, though
rarely before the second,  and commonly not till the third,  year  of
infancy ;  from which period it continues to prey on the system till
the  seventh, when, in ordinary cases, it gradually subsides and dis-
appears.   If the predisposition be not considerable,  the  attack is
sometimes postponed till after the seventh year, and has occasionally
been retarded till the  age of puberty, after which,  however, we
have very seldom any manifestation  of the disease.
  The first tumours we meet  with are usually upon the  sides of the
neck, below the ears, or under the chin; confined to the lymphatic
glands in these parts, and only spreading to the  salivary when the
disease has considerably advanced.   The tumours are, perhaps, two
or three in number, moveable, soft and slightly elastic, of a globular
or oval figure,  without  pain or discolouration  of the  skin.  In this
state they continue for a  year  or two:  after which  they grow
larger, and become more fixed; and acquire  a purplish  redness.
They then give a  feeling of greater  softness, and at length of
fluctuation : after which the skin, in one or more of them, becomes
paler, and a peculiar liquid is poured forth at several small aper-
tures,  apparently like immature pus, but growing  daily less puru-
lent, and at  length  assuming a curd-like form.  The tumour  or
cluster of tumours then subsides; but others rise in the neighbour-
hood ; and in this manner the disease proceeds, fresh tumours form-
ing, chiefly in the course  of the spring,  as the older disappear, and
the same  process is continued for several years: after which the
ulcers heal spontaneously  with puckered and indelible indentations,
provided the disease terminates favourably : but if not, other parts
 of  the system, as we have already observed, become tainted with
the morbid influence, and add to  the sum of distress.   If the attack
fall upon the eye-lids they become  inflamed, are swollen  and red,
and pour forth,  from their minute  glands, an erosive but viscid
secretion  which  glues them  together  at night,  so that  in the
morning they are  opened  with difficulty.   The  adnata  partakes  of
the irritation, which is at length communicated to  the whole globe
of  the eye, and not unfrequently  to the  cheek,  from  the acrid
discharge that  flows down.   An unsightly lippitude and eversion of
the lower eye-lid is hence a very common result of  a  scrophulous
attack on this organ.
   In like manner the disease, in this unfavourable and aggravated
   vor.. n.                   ft 7 
530
HiKMATlCA.
[CL. III.-OR. IV.
 state, often makes its assault on the limbs, and fixes on the ligaments,
 cartilages, or even the bones theniselv-s ;  and  particularly when-
 ever anv injury occurs to a joint.  An  indolent tumour first shows
 itself which tardily advances in magnitude with a kind of smothered
 inflammation, and at length opens on the surface from  one or more
 minute ulcerations which discharge the sanious kind of fluid we have
 already noticed.  And it is here we perceive how nearly scrophula
 is related to hydarthrus or white-swelling; and how  readily the
 former may become a cause of the latter, as already observed under
 that species.   If the strumous diathesis be excited by the fracture
 of a bone  the broken ends unite with great difficulty, and sometimes
 not at all.  A specific tumour forms  in the seat of the injury, the
 soft parts are often affected with a weak inflammation, and ulcerate
 slowly ; and  the bone is rendered carious.  If the  injury occur in
 the middle of a cylindrical bone an exfoliation may take place in a
 long course of time : but if at its extremity, it will become spongy,
 enlarged,  and disorganized.   If a cure be  at length effected, the
 enlargement  will  remain and  the  articulation be lost:  yet amputa-
 tion will be of no use while the part continues under the influence
 of the scrophulous taint.
   In the worst and severest stage of the disease, the entire system
 appears to be contaminated ;  hectic fever ensues,  and  sometimes
 tubercular phthisis which gradually puts an  end  to the contest.
  In attending to the cure, we must not be unmindful of the princi-
 ple we have  endeavoured to establish that scrophula is  a disease of
 debility principally affecting  the  lymphatic system,  accompanied
 with diminished irritability.   And it hence  follows that our chief
 dependence must be upon a tonic and stimulant plan, so modified as
 to meet the patient's age, idiosyncrasy,  and manner of life.
  How far an acrimonious  principle may be  generated, after the
 disease  has become aggravated  and general, it is difficult to say r
 but in its commencement, and while confined to the lymphatic glands,
 and indeed through the  whole of its ordinary and milder course,  it
 induces  diminished rather than exalted irritability, and consequently
 gives no proof of an acuating or acrimonious  source,    let such a
 source has been supposed even from its first appearance : and hence
 sedatives and narcotics have found a place  among  the  most  cele-
 brated of its remedies: while, as the chemical character of the ac-
 rimony has been also pretended to be developed, and has been de-
 clared to be a specific acid, another class of remedies  had recourse
 to has been the  alkalies.
  That  the latter are often of considerable  service ought, I think,
 freely to be admitted; but we have  assuredly no proof that  they
 become  beneficial as correctors of acidity.  They are gentle stimu-
 lants admirably adapted to the debilitated and indolent  condition of
 the vascular system they are intended to excite :  and hence in what-
 ever form they are given have a chance of  doing good.  And it is
to this principle we are  perhaps to resolve all the  advantage that
 has been stated by different writers, and in different  ages of the 
<SE. IV-SP. I.]       SANGUINEOUS FUNCTION.              531

world, to have resulted from the use of burnt-sponge, burnt cuttle-
fish, shells of all kinds, burnt hartshorn, and even burnt secundmes,
which last were at one time in high request, and are to be  found
a« a sovereign remedy in Schroeder's Pharmacopoea.*   All these
have in our own day deservedly yielded to the carbonate of soda, or
sub-carbonate of ammonia; which, in a more elegant and  concen-
trated form, offer whatever virtues may  be contained  in  the older
medicines.
   Lime-water, and the muriate of baryte, which last was  thought
by Dr. Adair Crawford  to be nearly a specific, if they have  any
pretensions whatever, can only derive them from the general prin-
ciple of their being stimulants and especially of the lymphatic  sys-
tem.   And the same may be observed of pctroselinum, sarsa, meze-
reon, balsam of sulphuro calamus aromaticus, and  horse-radish, all
of which have had their votaries in their day.
   Muriate of soda or common sea-salt  possesses a like character;
and has undoubtedly been found of far more use in many cases.  It
has, hence, been employed  very freely both internally and exter-
nally.  In the latter case very generally through the medium of the
bibulous marine plants, which contain it in a larger proportion, and
have been applied to the strumous tumours in the form of epithems ;
 as sea-wrack (fucous vesiculosus:)  sea-tang (alga marina,)  and  sea-
 oak (quercus marina.)
    The mineral waters  of every  description,  have in like manner
 been  had recourse to, chalybeate, sulphureous, and saline ; and per-
 haps, as  Dr. Cullen observes,  with nearly a  like  reputation  and
 success;  though it is by no  means improbable that some  waters
 may prove a more remedial stimulant or alterant to  some  constitu-
 tions, and others to others.  And we thus possess a more plausible
reason for their being advantageous than that offered by Dr. Cullen;
 namely that  " if they are ever successful it is the elementary water
 that  is the  chief  part  of  the remedy :"!  which  he tells us in
 another place may be of use by washing out the lymphatic system."!
    Stimulant  external applications, besides sea-water have also  been
 tried, and undoubtedly been often  found serviceable  ; as a  long con-
 tinued friction of the hand  over  the  scrophulous protuberances,
 mercurial or ammoniacal plasters,  or the convenient form in the
 London Pharmacopoeia that combines both  these  ingredients;  irri-
 tant ointments, the aura  of voltaism, or moderate shocks  of  elec
 tricity.
    The means of this kind, however, to  which we  have recourse,
 whether external or internal, should  always be gentle at first,  how-
 ever we may  venture upon  augmenting them afterwards. If we
 simulate violently;  we shall do mischief rather than good, and add
 to the debility instead  of diminishing  it.  Scrophula is  a  strictl\

                 * Lib. v. p. 288.
                 ' Piac. of Phys. Vol. iv. mdcclii,
                 !" Id. Vol. iv. "vmccr.r. 
532                    HJEMA'IICA.            [(3L. HL-OR. IV*

chronic disease; it never has been, and never  can be cured rapid-
ly; and wherever any beneficial influence has been produced upon
it, it has always been, as in the case of the alkalies, and of mineral
waters, by lenient means and patient perseverance.
  But we have to increase the  power as  well  as  the  irritability:
and hence tonics  seem to be as much demanded as stimulants; and
have in fact been as generally made use of.
  It is very singular that of this class of  medicines  the only one
which Dr. Cullen has thought it worth while to notice are bark and
colts-foot; of the first of these, he speaks very doubtfully; while
he seems to depend more on the second than on any  other remedy
whatever.  This  opinion he  expresses in his  Practice of Physic,
published 1783; but in  his Materia Medica, published six years af-
terwards, he gives it the same high character,  and tells us that he
was induced to try it in scrophulous cases upon the testimony and
recommendation of Fuller.   He employed both an expressed juice
of the fresh leaves, and a decoction of the dry : but  preferred the
former, of which he gave  " some ounces every day," and  affirms
that "in several instances it has occasioned the healing up of scro-
phulous sores."   He admits, however, that neither of them were in
some  trials sufficiently effectual.
  The metallic salts have been more  generally used, and have  at
least acquired a higher  reputation ; though, with the  exception  of
calomel, I do not  know any of them that  can appeal  to any decided
testimonies in proof of their success ; and even calomel may  per-
haps be regarded rather as an alterant or mild stimulant than as  a
tonic.   Salivation has always done harm;  and on  this account also
mercury in every form must be given in  minute doses.   Combined
with some preparations of antimony, and particularly with the pre-
cipitated sulphuret, as  in Plummer's  pills, it is said to have been
chiefly serviceable.  But in my own practice I  have  not found this
medicine of any manifest service in the  present disease.
  The acids have also  been tried, but  are of little or  no avail.
They who  regard  the  scrophulous  tairit as consisting  in  an acid
acrimony, are  apt  to  lay  hold of this fact in  support of their hy-
pothesis.  A better reason for their inefficacy is perhaps to be found
in their sedative property which we had occasion to  notice at some
length when treating of phthisis.
  Upon the whole, however, the tonic class of medicines has thus
far proved considerably less decisive and important in the treatment
of scrophula than we might  fairly have conjectured.   Yet a tonic
regimen of  sea-air, sea-bathing, liberal  exercise, and  a diet some-
what generous; is  of  the  highest consequence in  promoting im-
provement,  and ought by no means to be dispensed with.  The In-
firmary at Margate is on this account a noble institution, and cannot
be too liberally supported.
  Of the specific benefit of narcotics as hemlock,  henbane, fox-
glove, solanum, asclepias, vincetoxicum, and many  others,  I have
yet to be persuaded.  They may  possibly be of some use in quieting 
*E. IV.-SP. I.]        SANGUINEOUS FUNCTION.
533
the irritation occasionally produced by  congestion  and mechanical
pressure where the tumours  are peculiarly indurated and  large ;
and in such  cases may assist in softening and diminishing them.
And they may perhapsoperate in the same way where, in the later
and more malignant stages of the disease, the secretion  is become
virulent, the  open ulcers irritable, and  a foundation is hereby laid
for hectic  fever.  But  1 can conscientiously say with Dr.  Cullen,
that they have often disappointed me, and have not seemed to dis-
pose scrophulous ulcers to heal.
   The  local  applications, like  the internal remedies, should be
slightly stimulant; and, where the tumours have  broken, usually
consist  of  digestive  ointments  combined  with the caustic  metal-
lic salts of  mercury,  zinc,  or  copper;  and of digestive  lotions
of a dilute solution  of alum or nitrate  of silver.   These  are  well
calculated  to coincide  with the  general  intention; but  we must
not expect a sound cure till the morbid impression  is set at rest in
the constitution, or utterly extirpated from it.
                      GENUS   V.

                       CARC[NUS.

                           (fomrxr.

scirrhous, livid  tumour,  intersected with firm,  whitish,  diver-
  gent bands,  found chiefly in the secernent glands ; PAINS acute
  AND LANCINATING ;  OFTEN PROPAGATED  TO OTHER PARTS ; TERMINAT-
  ING IN A FETID AND ICHOROUS ULCER.

Of this genus there is but one known species: for the division into
occult and open,  or indolent  and ulcerative, introduced  by Hippo-
crates and continued till the  time  of Boerhaave  is  unnecessary  in
pathology, and incorrect in a nosological arrangement; as the dis-
tinctions it contemplates are  nothing  more than so  many  stages or
modifications of the same disease in different habits, or  affected  by
different concomitants.  This species is what is generally described
under the name of

     1. CARCINUS  VULGARIS.         COMMON  CANCER :
and it is not necessary to alter the term. 
534                     HiEMATICA.           [CL.  III.-OR. IV.


                         SPECIES  1.

               CARCINUS VULGARIS.

                     Common (Eancer.

TUMOUR  BURNING, KNOTTY ;  WITH DARK CANCR1FORM VARICES ;  ULCER,
               WITH THICK, LIVID,  RETORTED LIPS.

There is a soft, fungous and bleeding ulcer, possessing  the  name
of fungus haematodes, which has by  many writers of celebrity been
supposed to be  of a cancerous origin; and under their  authority it
has been so regarded in the  author's  volume on  Nosology :  but as
it seems to differ from cancer in its  constitutional influence and in
some of its local characters, it is better to contemplate it as a  malig-
nant ulcer of a peculiar kind: and in the present work it is refer-
red to that genus accordingly.
  Some writers have offered many other  subdivisions which  are
still less entitled to a distinct  enumeration; as Bierchen,  who  has
given us five under the  names  of the genuine,  the  strumous,  the
syphilitic, the fungous, and the  noma.*  Of these the  first  consti-
tutes the species before  us;  the second and third  are modifications
of the same, only varied by  the idiosyncrasy or incidental state of
the constitution; and the last two are depraved ulcers.
  The term carcinus (xxfxnos)  is Greek, and imports  a  crab;  the
disease  being thus called from the cancriform or crab-like ramifica-
tions of the dark, distended  veins of the cancerous tumour.   The
question is of some consequence whether cancer be a constitutional,
or a local, whether an hereditary or merely  an  occasional disease.
Much has been  said^ and well said, on  both sides.   Till  of late years
the disease was generally regarded as a constitutional affection, and
will, for the most part, therefore, be found in the division of cachex-
ies from Sauvages to Macbride,  though Dr. Cullen has introduced it
into his class locales:  and since  his time  many of the  best writers of
the present day, among whom are Dr. Baillie and Mr.  Abernethy,
concur in regarding it as local alone.  If the disease  be merely lo-
cal, it is difficult,  and perhaps  insuperably difficult, to say  why a
blow on a conglomerate gland,  as the breast for example,  should
sometimes produce a cancer but more generally  not:  or what  that
power is that excites the cancerous action in one person, from which
another, or perhaps a hundred others, remain free upon an applica-
tion of  the very same injury to the  same  organ.  A blow  on the
knee often produces a white swelling;  but ten  thousand children
receive blows on the knee  without  any such effect  following.  In
this case we resolve the difference of result, without a  controversy.
Abhandl. von den wahren kennzeichen des Krebsschadens, &c. Go^t. 1775. 
UE. V.-SP. I.]         SANGUINEOUS  FUNCTION.           535r

into  the presence or absence  of a  scrophulous  constitution; and
without this view of the subject we should find  ourselves at a loss
for an answer.  And unless we apply the same reasoning to cancer
we shall ever, I fear, remain at an equal  loss.  The  cases, more-
over, in which cancerous tumours are found  in  other parts of the
body after one, or more than one, has been extirpated lead us by an
easy thread to the same conclusion, provided the tumour has been
removed in an early stage of the  disease, and before ulceration has
taken place ; for  it is possible that the specific  matter of a cancer,
generated and matured locally, may be absorbed and  deposited on
the organs which are afterwards  affected.   But if  the  extirpation
have taken  place before the formation of  the specific matter, it is
not easy, except by a constitutional taint, to  account for any subse-
quent appearances.
   It is still stronger in proof of an hereditary  predisposition that
various members of the same family have exhibited the same dis-
ease either simultaneously or in succession ; and that the descendants
of those who have been  afflicted  with it seem  to  have more fre-
quently suffered from it than others.   It is not necessary to  advance
individual  instances in support of these positions.   The  same re-
marks  have been  made upon a general survey  of the disease  in
most ages;  and the doctrine of an hereditary influence  has, in con-
sequence, descended to us as a result of such remarks from  the time
of the Greeks and Romans.
   The truth seems to»be, that cancer, like gout, is  dependent upon
a peculiar diathesis or state  of the  constitution, which disposes  a
scirrhous tumour, or any other occasional cause, to produce a can-
cerous ulceration, and consequently to generate the specific matter
of cancer;  which  matter,  once  absorbed into  the system, even
though, by a removal of the local affection, and the influence of a
healthy habit, it should remain dormant or  be  kept  in subjection,
may  augment the  original  predisposition, and transmit a seminium
to the future race.
   How far a predisposition to cancer, whether original or derived,
may manifest itself by external signs, I am not  able to determine.
Such an outward  character  is by no means  constant in the list of
hereditary diseases.  It is  perhaps generally visible  in those that
affect the mind; but far less so in  those that affect the body.   In
phthisis, the predominant diathesis has a striking exterior;  in scro-
phula,  the outward and visible sign is far less distinct, though such
a sign seems to prevail generally  : in gout, there is no specific  ex-
terior that we can depend upon.  Dr. Parr, however, has conceiv-
ed that cancer has its outward  character  as  well as  phthisis, and
that it  is indelibly marked in the complexion : " for  we have found,"
says  he, " cancers more frequent in the  dark cadaverous complex-
ions, than in the fairer kind.   The complexion  we mean is  distinct
from the darkness of the atrabilious or melaneholic habits: a blue
tint seems mixed with the brown, and is chiefly conspicuous under
the eyes, or in the parts usually fair.  This may, perhaps,  be a re- 
536
HiEMATK A.
[CL. 11I.-OR. 1\.
finement without  foundation, but we think we have often observed
it.  There is certainly no constitutional symptom  by wjuch it  can
be predicted, if, in women, a scanty and a dark-coloured catamenial
discharge be not  a prognostic of the future disease.  Cancer  has
certainly been traced in females of the same family;  and those who
have escaped suffer from irregular anomalous pains, and different,
often  unaccountable, complaints."*   The picture  thus ingeniously
drawn  is worth bearing in mind, but I have never been able suffi-
ciently to appropriate it;  and in the  last  two or three cases of can-
cerous breasts that have occurred to myself, the patients have been
of fair  complexion, and light  hair: one of them, indeed, peculiarly
so : the lady was  about fifty, and had had a large and  very  hand-
some family, all of whom  were so  fair as to make a near approach
to the  phthisical exterior, though none of them have ever exhibit-
ed its pathognomics.
  Cancer has also  been  imagined by many practitioners of high
respectability to be contagious ; of whom we may mention Bierchen,
Sinnert, and Gooch;  but there seems no  sufficient ground for  the
continuance of such an opinion.  Inoculation has been said to have
produced the  complaint; but, like many other  specific acrimonies,
it does not act very readily in this way, even if it act at all;  for M.
Alibert affirms that he inoculated both himself and several of his pu-
pils, without any  other effect than that of local inflammation ;  and
that even this did not always ensue.!  It has been swallowed by dogs
without any mischief.J
  The  parts  most  usually affected  by cancer are the excretory
glands, and especially those that separate the fluids to be employed
in the  animal  economy, rather  than  those that secern  the  excre-
mentitious part of the blood.  The lymphatics are seldom primari-
ly affected, though  they may  become   tainted  from  their con-
tamination with a cancerous  part.  "• I never yet," says Mr.  Pear-
son, "  met with  an  unequivocal  proof of a primary (cancerous)
scirrhus in an absorbent gland."§   And hence we behold a striking
difference between the nature of cancer and scrophula.  But though
the secernent glands are most open to the attack of cancer, any part
of the body may become its seat.  We meet with it, however, chief-
ly in the breasts of females, the uterus, the  testes, the glans  penis.
the tongue, stomach, cheeks,  lips, and angles of the eyes.  The ob-
struction commences in the minuter vessels; and the adjacent parts
are affected in consequence.
  Women are more subject  to cancer than men ; and in these  the
mammae  and the uterus are the organs most predisposed to its in-
fluence.  Celibacy, as well as the cessation of the  menses, conduces
to its production  or  appearance ;  and  hence antiquated maids  are
* Med. Diet, in verbo.
t Maladies* du la Peau, &c.
X Le Febure, Femede, Sec. 1776.
ft  Principles of Surgery, &c. Vol. i. p. 209, &c. 
C.E. V.-SP.  I.]       SANGUINEOUS FUNCTION.              537

mostly affected with it; and next to these, mothers  who  have not
suckled their children, for we may lay it down as an axiom, in the
language of Dr. Parr, that a milk abscess never becomes  a  cancer.
Then follow women who are past child-bearing.  And lastly, wo-
men who have borne children  and  suckled  them with their own
milk, and males incidentally exposed to its occasional causes.  To
which we may add, that when cancer occurs in men it is chiefly in
the lips, and when in children, in the eyes.
  Of the remote cause of cancer we know nothing.   While scro-
phula has been supposed  by some to be the result of an acid  acrimo-
ny ; cancer has by others been supposed to be produced by a pecu-
liar alkali.  Dr. Crawford, from a  series of very curious  experi-
ments upon the matter of cancer, thought he had ascertained this to
consist principally of hepatised ammonia, and found  that this matter
effervesced with sulphuric acid.*  Ploucquet, however, affirms, that
it sometimes effervesces with alkalies as well.!   The taste discovers
nothing; for to  the tongue  it  is insipid and  mawkish rather than
acid or alkaline.   Yet Parr, laying hold of Crawford's experiments,
has boldly  ventured to assert that the remote cause, or rather the
i-.ause of the  cancerous diathesis, consists in an excess of ammonia
with a redundant developement of sulphur.
   When it was popular in the Linnean school to resolve almost all
diseases into the irritation of worms, grubs, or insects existing pa-
rasitically  in different organs of the  body, cancer was by some theo-
rists supposed to depend upon a like cause : and the hypothesis has
been since adopted by several writers  in our  own country, as Mr.
Justamond, who ascribed it to the larves of a  particular  species ot
insects, and Dr.  Adams, who referred it to hydatids.J   Vermicles  or
the larves of insects have at times been found in  the  open  ulcer of
a cancer, as in the  fetid discharge of  many other malignant ulcers.
These, as in other cases, have undoubtedly proceeded from eggs de-
posited in the sore  as a nidus, though  the  worm or insect  that has
so deposited  them  has never been detected.   Such  appears to be
the foundation  of  this hypothesis,  which we  have no authority
for  carrying farther,  and which  is rarely advocated in the pre-
sent day.
   The occasional or existing causes are numerous: but  to account
for their efficiency it seems indispensable, as we have already observ-
ed, to suppose the existence of a cancerous predisposition or diathe-
sis, since we see the same causes  acting  in  innumerable instances
daily, without betraying any tendency to such a result.  Where this
is present it may be produced by an external injury upon any of the
parts most susceptible  of cancer; by an  indurated  and chronic  tu-
mour incidentally inflamed or irritated: an accumulation  of acrid
filth in the ruga? of the skin which is a frequent  cause of cancer in
        * Phil. Trans. Vol. lxxx. 1791.
        t Init. Biblioth. Tom. n. p. 202.
        + Observations on Morbid Poison*.
vol,,  rr.                08 
538                     H/EMATICA.            [CL. III.-OR.  IV.

the testes, and particularly among chimney-sweepers:  the hardI and
pungent pressure of a wart or  corn  in  an irritable habit, of which
the medical  records  offer various  examples; the acrimony  of an
herpetic eruption ; the general disturbance  produced in the system
by a severe attack of small-pox, or several other exanthems; a sud-
den suspension of a periodical hemorrhoidal flux and a cessation of
the menses; and, when in the  stomach, by a previous life of ebrie-
ty or irregular living.  With these severe cold  seems  also to co-
operate,  as the disease is  generally admitted to be both more fre-
quent and more virulent in the high northern latitudes than in the
southern regions of Europe.
  When  cancer takes place in the breast, it usually commences with
a small indolent tumour that excites little attention.  In process of
time, this tumour is attended with  an  itching, which  is gradually
exchanged  for a  pricking, a shooting, and at length a  lancinating
pain, a sense  of burning, and a livid discoloration  of the skin.  And,
however difficult it may be to determine  the precise point  of time
in which the  scirrhous first becomes converted into a cancer, where
these symptoms  are  united  there can be no risk in calling the tu-
mour by  the latter name.  Adhesive bands are now formed in the
integumeuts which become puckered; while the nipple is drawn
inwards by suction, and  in some  instances  completely disappears:
the tumour rises higher towards the surface and feels  knotty to the
finger; at the same time that the  subcutaneous vessels are  distend-
ed with blood and show themselves in dark cancri-form  varices.
The march of the disease  may be slow or rapid, for it varies con-
siderably in its pace ;  but  at length the integuments give way in a
few points  to the ulcerative  process, and a small quantity of caustic
ichor, or of lymphatic fluid  tinged with blood from the eroded ves-
sels, is thrown forth,  sometimes with short and deceitful relief: the
ulcerative process in the mean time advancing, and spreading wider
and deeper till a considerable extent of surface becomes exposed,
and a broad excavation is scooped out with a discharge  of a pecu-
liar and most offensive fetor.  Here again the ulcer sometimes af-
fords a delusive hope of recovery by its granulating;  but the gra-
nulations are  soft and  spongy, and not unfrequently bleed from  the
loose texture of the new vessels, or their erosion  by the cancerous
matter.   It is rarely, moreover, that they extend over the entire
surface of  the sore ;  for more  generally while one part is  covered
with them  another part  is sloughing, and each of  the parts runs al-
ternately into the action  of  the other.  And not  unfrequently  the
lymphatic vessels become affected as high up as the axilla?, and in
their course betray a  few  smaller tumours.   But  whether this is  a
mere  result of contiguous  sympathy or of cancerous taint, is uncer-
tain.  Cancer, as we  have already  observed, rarely, if  ever, com-
mences in lymphatic glands, which show a peculiar indisposition to
the power  of its seminium;  but they, at length, partake of the  dis-
ease in the course of its ravage; and hence  all such suspected tu-
mours are  prudently removed  when the knife has been resolved 
GE. V.-SP. I.]        SANGUINEOUS FUNCTION.              •■>«^

upon. Where the disease has spread widely or continued long, some
of the muscles of respiration  participate in  the  irritation, and the
breathing is performed with difficulty.
   When cancer attacks the uterus it is known by tensive  lancinat-
ing pains in this organ, shooting through the region of the pelvis ;
indurations in the part sensible to the touch;  a  preceding and im-
moderate leucorrhoea, or menstruation ; sometimes both.  The ul-
cerative process, as far as we are acquainted with it, is the same as
already described; and as soon as it  has  worked to the surface oi
the organ, there is a sanious, or bloody, or mixed discharge charac-
terized by the peculiar stench of the disease.  By degrees, the  labia
swell and  become  edematous; and if, as  sometimes  happens, the
inguinal glands be obstructed, the edema extends along the thigh.
   Cancer in the vagina  which, however, rarely  takes place, can
easily be felt, and in the rectum the distinction is not difficult.  The
nature of  the discharge, and the other symptoms  just noticed, are
sufficient to decide its existence.   It  is still  more obvious in the
penis.
   None of these symptoms  assist us in determining its presence in
the stomach : and hence how confidently  soever it may be  conjec-
tured from  the marks of an  acute and burning  pain, tenderness of
the epigastrium  upon pressure,  nausea, and rejection of food, and
even an offensive fetor in the breath, the disease can seldom be
completely asertained till after death.
   The  progress of cancer in the testicle is often slower than in  many
other parts. In  chimney-sweepers we can trace an obvious cause,
which is that of soot lodged in its rugae, and irritating as well from
its own acrimony as from that of the perspiratory fluid with which
it comes in contact and forms an union.  A painful ragged sore with
hard rising edges is first produced ; or, sometimes, a little indurated
wart; which, from inattention, increases  in size, is repeatedly rub-
bed  off by the exercise of climbing, enlarges and deepens its sphere
of irritation, grows more malignant, and at length  is converted into
a real cancer, and affects the  whole scrotum or the body of the testis.
In whatever part of this complicated organ,  however, the disease
 commences, it is progressively communicated to the rest; the scir*
rhosity increases in size and hardness, till  the tumour  often acquires
 an enormous and irregular magnitude, studded externally with nu-
merous protuberances, and the shape  of the testis, even before ul-
ceration, is entirely lost.  In the  progress of the disease,  the  sper-
matic chord becomes affected, and the taint or irritation is communi-
cated more or less to the viscera of the peritoneal or lumbar  cavi-
 ties.
   From the cancerous effect of a highly irritable wart or crack on
the scrotum of chimney-sweepers, we  may derive  some idea of the
formation of cancers on  other superficial  parts of the body from  a
similar beginning. These most frequently  occur on the lips, nose, or
eye-lids ; and oftener from a crack than  from a wart.  The  edges
of the sore become hard, and one or more tumours issue from  them,
which increase  in size and gradually evince a cancerous character. 
540                      ilematica,          [cl. hi.-or.  iv.

  On the  tongue the same disease  sometimes  shows itself; and
more usually commences with a small wart or  pimple near the tip,
which hardens by degrees, grows highly irritable and malignant, and,
spreading its influence through the entire organs, swells it to a pro-
digious size and renders it of a scirrhous induration.
  Cancer is said, in  a few  instances,  to have terminated spontane-
ously.  De Haen gives us  one example  of this :* and Parr affirms
that he has seen six  cases of the same in his own practice.  But he
adds, in proof of its  being a  constitutional affection, that in every
case the  cure was followed by some  other  disease, as an enteritis,
fixed pains in the limbs, a  sciatica, or an apoplexy, in one of these
cases the apoplectic  attack occurred  twice, and  the last was fatal.!
  In general, however,  a cure is rarely affected but by the knife or
a caustic, the use of which it does not belong to the present course
of study  to explain.   Yet  the progress of the  complaint may per-
haps be arrested; and we are often able, without cutting, to render
it, at least tolerable, for a series of years.   In an early stage of the
disease relief may often be obtained by topical bleeding, as with
leeches ;  and  topical  refrigerant applications, as saturnine lotions, or
sheet-lead in very thin  layers, as the linings  of tea-packages, an
application which has of late been brought forward as  something
new, but which  was  employed long  ago, and may  be found recom-
mended  in many of the older journals of  established reputation.^
The diet should be  limited to the  mildest nutriment, and wine he
sedulously avoided.   At  this period, indeed, whatever can prevent
or lessen inflammation should  be seriously studied, and adhered to.
  Ponteau relates the case of a cure produced by rigid abstemious-
ness alone, the  patient  taking nothing  whatever  but water  for a
period of two months.§
  As, however, the disease advances  and assumes more of a chronic
character, the activity of the  smaller vessels may be  gently urged
in order  to relieve or prevent congestion.   And, where the irrita-
tion is not great, we may by degrees  apply gentle  stimulants also
externally, and let the saturnine lotion be superseded by the acetat-
ed  solution of ammonia, tar-water as recommended by Quadrio, or
an illination of the surrounding parts  with mercurial ointment com-
bined with a small portion of camphor.
  The internal medicines which have been chiefly trusted to  for
the cure of cancer,  are the lurid  and umbellate narcotics and  the
mineral  tonics: the  former apparently for the purpose  of taking
off irritation, and, in some  instances, correcting the specific acrimo-
 * Epist. De Cicuta, p. 43.
 i Diet, in verb. Vol. i. p. 329.
 X Eph. Nat. Cur. Dec. i. Ann. iv. v. Obs. 161.
 i Nuovo Metodo per curare sicuramente ogni Canchero coperto, &c. Venezia4
1750.
 Oeuvres Posthumes, Tom. r. 
CE  V-SP. 1.]       SANGUINEOUS FUNCTION.               541




■"of^todSftrSSf have been the belladonna and hem-





practitioner was eager  for examples «pon wbich to *y  ^eggn-
 mpnt for himself   Solanum had been in vogue but was just ^nKin5
 Kfdtarepute frim its  numerous failures: and corrosive sublimate
 « tt marine chiefly confided in atSt-W^^
 Akenside  who was at this time prescribing the corrosive suDiimdie
 fZI hospital, with, what he thonght, a gratify nfsnc^.mm^d-

 ately  exchanged it for  the —,.r» *s £•£*»££*
 He tried it, upon a large scale, in  every stage dim u
 the disease, and at firsAvith the most sanguine expecRations   Bu
 his hopes gradually tailed him as he advanced m the career 01 nis
 experiment;  and he was  compelled to make J07 great draw-backs
 upon Dr. Stoerck's commendation of  the medicine.  He allows it,
 however  a certain degree of merit,  and his account is  drawn up
 wifh a degree of candolr  which entitles it to the fullest confidence
 Tnd appeal to deal out the real truth.  In -cent states of the d-
  ease where there was  no  ulceration, or none of any depth, he assert,
  ttat  Soften produced a  favourable termination,  and  gives nume-
  rous examples to this  effect.   But in inveterate cases where the
  c^r leer bad  made ^^-f J^fi? ^

  SS^^pK^C^ thVeedischarge^ but suddenly l{
  faiTed to do he slightest good  any longer, unless the dose were very
  artelv increased ^ipon  which a  like beneficial effect followed;
  bTunVr^atdy of Squally transient  duration.   The^> was  in
  manv instances,  again  increased;  and continued  to be  so,  till at
  Sh the symptoms  produced by the cicuta were as mischievous
  as those of ic cancer itself,  and  Dr. Akenside  was compelled to

  ^We're'hence in some degree  prepared for the contradictory ac-
  counts of its effects whichWre furnished by different wtiter..  De
  Haen  asserts that it affords  neither  cure nor relief of any  kind.T
  Berchen, that it aggravates real cancer, though sometimes servicea-
  ble in scrophulousf and Lange, that it is altogether inefhcacious.§

             * Transact, of the Col. of Pbys. of Lond. Vol. 1. Art. vi. p. 64.
             t Rat. Med.  11. 37.
             X Loco, citato.
              Diss. dubiaCicutse vexata. Helmst. 1764. 
«
 *>42                      1MSMATICA.          [CL. Ill.-OR. IV.

 Fothergill is friendly to its use ;* and Bellt and Fearon* recommend
 it both externally  and internally,  alone  or in combination  with
 opium.
   For this discrepancy of judgment we  have in some measure endea-
 voured to account.  Yet the advocates of the medicine have, doubt-
 less, in  some  instances, suffered themselves to speak of it in exag-
 gerated terms; and it is  highly  probable that in others, where it
 has seemed altogether inefficacious, the hemlock, whether in pow-
 der or extract, was  administered in an imperfect state.  Dr. Cullen
 gives a  striking example of this last fact in a lady who, being very
 particular in  the use  of this medicine, employed the powder as
 mostly to be  depended upon, and weighed out her own doses, begin-
 ning with a small quantity at  a time and  proceeding gradually till
 she took  sixty grains  at once.   By this  period her parcel of the
 powder  was exhausted; and she had derived  no beneficial effect.
 She  supplied  herself,  however, with  another  parcel, and being
 warned  that different samples were rarely of the same strength, she
 reduced her first  dose  of the new plant to a scruple: yet even this
 nearly killed  her: for  in ten or fifteen minutes she was  affected
 with sickness, tremor, giddiness,  delirium and convulsions.   Happi-
 ly the sickness proceeded to a vomiting, and the poison was reject-
 ed.  But of the fresh supply she was never afterwards able to take
 more than five or six grains at a dose, notwithstanding she had taken
sixty grains of the preceding without any mischief.§
   Yet the  quantities pretended to be  given by some practitioners
 are far  beyond this last amount.  Thus, Dease informs us that he
gave an ounce and a half of the powder every twenty-four hours,[|
and performed a cure ; and Rostard that his ordinary allowance was
six drachms of the extract for the same period, which is a still high-
 er proportion.IT   Warner gave a  drachm  and a half, and thought it
 an enormous quantity, without mischief.**
   Upon the whole, the balance of experiments seems very  much to
 confirm  the candid  report of Dr. Akenside.  Schaeffer, and many
 others contend that even its  beneficial influence  is nothing more
 than a result  of its narcotic  power: but it does seem, in some in-
 stances,  to  act as a discutient, and  to improve  the  quality of the
 secretion as well as to relieve the pains. Dr. Cullen advances further,
 and tells us that he  has found it in several cases, make a considera-
 ble approach  towards  healing the sore; " Though  I  must own,"
* Works, Vol. n. passim.
t On Ulcers, Part n. Sect. vm.
X On Cancers, passim.
v Mat. Med. Vol. n. Part n. Ch. vi. p. 264.
|| Introduct. to the Theory and Practice of Surgtry. I.
IT Journ. de Med. Tom. xxxvu. p. 36.
** Treatise on the Eyes, passim. 
GE. V.-SP. I.]
SANGUINEOUS FUNCTION.
543
says he, " that I was never concerned in a cancerous case, in which
the cure of the sore was completed."*
  Of the other narcotics, chiefly of the solanaceous order, that have
been  employed, it is hardly worth  while to speak  particularly.
The same uncertainty has accompanied their use : and some of them,
as aconite and dulcamara, have been rather supposed to effect what-
ever temporary benefit  has flowed from their employment by the
general disturbance they produce in the system, whereby a transient
stop is put to every  other anomalous action, than by their sedative
power.
   Of the metallic oxydes that have been brought into  use, the only
ones itis necessary to notice are those of mercury, iron, and arsenic.
The first has been uniformly found mischievous when carried to the
extent of salivation.   Loss asserts that by this  mean he has cured a
cancer of the  nose and  face ;t but this was probably a spurious dis-
ease of zaruthan,  as  it  has been  called by  some  writers.  It has
more  generally been employed as a gentle  stimulant or alterant.
Many practitioners have preferred the corrosive sublimate in small
doses; but the  submuriate is  a far better preparation.   And even
this is given with more  advantage in the form of Plummeris, or the
compound calomel pill, than alone, a form that conveniently unites
a mild stimulant with a  mild relaxant. To this,*if the pain be acute,
should be added a small quantity of opium ; at the same  time care-
fully  guarding  the bowels against constipation  by any  convenient
aperient, if the pill itself should not prove sufficient.
   Iron has been tried in  almost every state of combination, and there
is reason to believe that in some of these it has proved beneficial.
The ferrum ammoniatum appears to have  been the most successful,
and is still the most popular.   Under the  name  of flores marliales
it was introduced  for this purpose  before  the public as far back as
the middle of last century, by Francis Xavier de Mars, obtained,
however, by a very  uncouth  and operose process.  Dr. Denman
was particularly attached to this metal in whatever form administer-
ed, and  broadly affirms that after having  employed almost all the
medicines  recommended for this  disease in  every different stage,
he  has never found any of them possess the pretensions of iron ; and
that the rest may be  generally regarded as totally unavailing.^   Its
greatly stimulant power rather recommends it to us on the present
occasion than proves an  objection ; for it is the kind of stimulus we
stand in need of to excite a new local action.  It is said  to produce
a very speedy mitigation of pain, an improved discharge, and  a less
fetid smell: and, even in hopeless cases, to render the disease less
malignant and distressing:  unfortunately,  however, its effects, like
those  of conium, have  rarely  been  found permanent;  and it has
closed its career as a palliative rather than as an antidote.

          * Mat. Med. loco, citat.
          t Observ. Med.  B. iv. Lond. 1G72.
          X Observations en the cure of Career, p. 77. 
544
H/EMATICA.
[CL. III.-OR. IV.
  But of all the medicines of this  class arsenic has  acquired the
highest and most extensive reputation.   This is a strictly oriental
remedy, employed, as we shall have occasion more fully to observe
when treating of elephantiasis, for every impurity of the  blood.
Who first ventured upon it in Europe for the disease  before us, is
not very satisfactorily  known.   It was common in the time of Hil-
danus  who ascribes its introduction into practice by  the  monk
Theo'doric, who  flourished about  the beginning of the eleventh
century*  It has formed the basis of almost all the secret remedies
for cancer  which have at any time been current, whether external
or internal, from that of Fuschius, in the  fourteenth century, who
united  it  with soot and scrpentary,  to that of Richard Guy  who
wrote upon the disease?  in the middle  of the last century, and  whose
boasted arcanum was found to be a composition of arsenic, sulphur,
hogsfennel  (peucedanum  officinale,)  and  arows's-foot (ranunculus
syh:esiris.)l
  Of the real effects of arsenic, as of several of the preceding medi-
cines, we labour under great obscurity from the discrepant reports
which have been  communicated.   Le Febure with  a host of practi-
tioners  antecedent to,  and contemporary with himself, employed it
both externally and internally, and regarded it as a specific.§  Smalz
thinks it serviceable.j|   SchneiderlT and Justamond declare it to be
useless, though the'latter employed it locally as an escharotic.  Hil-
danns** and Deliusff assert  it to  be  injurious; and SchenckfJ and
Meibom§§ give examples of fatal effects from its employment.
   Fatal effects,  indeed, it is  easy to  produce,  provided a sufficient
degree of caution be not employed in experimenting upon it.   And,
in truth, it is  not  till lately *hat any very convenient form has been
devised for trying its  virtues  without a  risk of mischief; but the
arsenical solution  of the London College, for which  we are indebted
to Dr. Fowler, has  given us a preparation of this kind.  Yet even
with this advantage we cannot boast of any certain success in the
use of  arsenic.   It acts very  differently on  different constitutions,
though generally speaking it proves beneficial;  and in some  cases
may produce a radical  cure.  But more  commonly, like the pre-
parations of hemlock and iron, it  unfortunately loses its effect as-
  * Cent. vi. Obs. 81.
  t Essays on Scirrhous Tumours and Cancers. 1759.
  % Richter, Chir. Bib). Band. v. p. 132.
  $ Rpniedc eprouv^ pour guerir radicalement le Cancere occulte, et manifcste ou
ulcere. 8vo. Paris.
  || S'ltene cbirurgische und medicinisch.e Vorfalle. Leips. 1784. 8vo.
  If Chir. Geschichte, Theil. v.
  ** Account of the methods pursued in the treatment of Cancerous and Scirrhous
Disorders. Lond. 1780.
  'ft Divert. Observat. et cognit. nonnulia chirufg. Fasc. vi.
  XX Observ. Lib. II. N. 304.
  ^ Blsimenbach. Bibl. Band. vm. o. 724. 
GE. V.-SP. I.]        SANGUINEOUS FUNCTION.              545

soon as the habit has become accustomed to its influence, and the
cancerous taint, or cancerous action, resumes its victorious career.
And perhaps the only power that is capable of neutralizing cancer
or keeping it  permanently in subjection is the existence of  a pre-
dominant diathesis of  some other kind.   How far the remark may
have been made  antecedently I know not, but, from  a  pretty close
attention to  the subject  within  my own sphere  of  observation, 1
have been led to conclude that cancer does not often make  its at-
tack upon those who are constitutionally subject to gout, and seems
to be restrained by its influence.
   The list of external applications is still more numerous than that
of internal.   We have already glanced at the local treatment before
ulceration has taken place.  After this period, sedative applications
do not succeed, and moderate stimulants alone seem best to afford
relief.   In fact, the inflammation has now acquired much of the
character of a malignant erythema, and requires  warmer applica-
tions than phlegmonic sores.  Yet a cure is rarely  to be effected
except by a caustic or knife.   When the poison was supposed to be
of an acid character a solution of the alkalies was employed  to cor-
rect it, and the ammonia produced from burnt toads was at one time
in very high repute.   It was afterwards conceived to be of an alka-
line nature ; and various  acids,  and particularly the carbonic acid
gas, were regarded as the best antagonists.  Who first employed it
for the present purpose is not known; but it stands recommended as
early as 1776, in an article  of Magellan, inserted in  Roster's Jour-
nal ; and an easy and  convenient mode of application  has lately been
contrived by Dr. Ewart of Bath.  Dr. Crawford,  however,  for the
same purpose preferred a lotion of muriatic acid diluted with three
or four times its weight of water.  Carminati and Senebier applied
the  gastric  juice of animals; but poultices of carrots or charcoal
have of late years been in more  general reputation.
   All these  have a considerable  influence in correcting the oppres-
sive fetor, and keeping the sore clean; but whether they go  beyond
this has  been doubted.  Yet even  this is of great importance, since
such an  effect must  necessarily give some  check to the spread of
the ulceration, afford solace to the patient, and probably improve the
nature of the  discharge itself.  And hence  many writers have been
sanguine enough to expect an entire cure from such  processes ; and
others have given accounts of such cures nearly accomplished ; but
which seem seldom, if ever,  to have been rendered complete.
   Fomentations of hemlock and various  other narcotics  have been
also  had recourse to, and sometimes  tepid baths of the same, in
which the patient has been ordered to sit for twenty  minutes at a
time ; and temporary  benefit has sometimes followed the use of these
means ;  but they have often  been tried  with  as little avail as the
sucking  of toads, which was at one time a fashionable  remedy, and
esteemed of great importance, the animal* being feigned to expire
in agonies as the poison of the  ulcer was drawn out, and its  surface
assumed a better aspect.  Bouifey, who  was a witness to their use,
   vol. rr.                  69 
546
Htf.MATICA.
[CL. III.-OR. IV.
tells us,  and  probably with  some  truth, that they did more  harm
than good,* and dealt out more poison than  they took away.   The
era of this invention is unknown, but it was still in use, about  half a
century ago in  our own  country if we may judge from one of the
private letters of Junius to Woodfall, who alluding to the princess
dowager of Wales, at  that time afflicted with a cancer that destroy-
ed her in January 1772,  asserts that " she suckles toads from  morn-
ing till night.'"t
  One of the best detergents appears to be arsenic finely  levigated
and  sufficiently reduced  in strength by an union with calamine or
some other ingredient.  It is also one of the best caustics,  in a sim-
ple or more concentrated state, and was freely employed as such by
Mr. Justamond. Guy's powder,  which we have  already noticed, is
used externally for the same purpose.
  We have already observed that sheets of lead, among other pre-
parations of this metal, were  applied to the cancer about forty or
fifty years ago, and bound over ft with  some degree  of  pressure.
But a pressure of a much severer kind together with the use  of the
same metallic sheeting,  has of late years been  employed by Mr.
Young and apparently in many cases with a very salutary  effect, so
far as relates to checking the spread of the disease, a diminution of
the  tumour,  and an improvement of the nature of the discharge.
The plan, however, has failed in  many instances; and how far it
may have produced in any instance a decided cure, the author can-
not positively affirm.   The sheet-lead is applied  with a considera-
ble  tenseness of compression by means of plaster-straps, tin-plates,
folded  linen,  and appropriate rollers.  The force employed how-
ever is less severe at first,  but progressively increased; and the
change of action is with much  more reason ascribed to the sedative
effect of the mechanical pressure than to that of the lead.
  After all, when the  cancerous character of the tumour is once
decidedly established, there  is little dependence to be placed]? upon
any  plan but  that of extirpation by a caustic or the knife.   The
actual cautery as employed by M. Maunoir, of which we shall have
to speak more at  large when discussing the genus Ulcus,  may per-
haps be most advantageously  made use of in small cancers of the
face, but the  knife is the preferable instrument where the organ is
large and  extensively affected.  Mr. Bell advises an early  perform-
ance of the operation; Mr. Pearson,  that we should  wait till the
extent of the  disease has  fully unfolded itself, so that no morbid part
may be  left behind.  Yet some parts may be doubtful even at last,
and, wherever there is the least suspicion of this, they should un-
questionably  be removed along with the more decided portion of
the  morbid structure.
  Even this  remedy, however, can only apply to exterior organs.
In all other instances, the practice is melancholy from  the first.
* Journ. de Med. Tom. 1.XII.
t G. Woodfall's Edition, Vol. I. p. *241. 
GE. V.-SP. I.]
SANGUINEOUS FUNCTION.
547
The die is cast almost, if not altogether, irrecoverably :  and all we
can hope to  accomplish is to  postpone the fatal result,  to mitigate
the sufferings of the day, and soften the harsh passage to the tomb.
                      GENUS  VI.

                            LUES.

                      Sfcnereal fflxtam.

 ULCERS  ON THE GENITALS, INGUINAL BUBOES,  OR BOTH, AFTER  IMPURE
   COITION; SUCCEEDED  BV  ULCERS  IN  THE  THROAT,  COPPER-COLORED
   SPOTS ON THE SKIN, BONE-PAINS AND NODES.

 The term lues is derived  from  the Greek Xva>, " solvo, dissolvo"—
 u 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 xXva or xXva-n, we  are  supported by a similar example of
 deviation from the common  rule.
  It appears to have been known to the world from "an  early  age,
 as I have remarked in the running comment to the volume of No-
 sology, that acrimonious and poisonous materials are, at  times, se-
creted 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  va-
rious diseases of the sexual  organs, most of which are only refera-
 ble to this source of impure contact;  but the hideous and alarming
 malady which  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 the 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. 11. 
548
H^EMATICA.          [CL. HI.-OR.  IV.
Richter,* Stoll,t and  other  writers  of considerable eminence, re-
garded  as of far higher antiquity; asserted by Lefevre de Ville-
brunej to have existed eight centuries before the expedition of Co-
lumbus to America, and by De Blaguy§ to have  been extant in the
Mosaic  age.
  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
now 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 hitherto undiscovered ; and which are accompanied with pri-
mary  and secondary symptoms that often vary in their mode of ori-
gin, 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  1 think be obvious  to every one.

       1. lues syphilis.           pox.
       2.----syphilodes.        bastard  pox.
* Chir. Bibl. Band. i. Sect. ii. p. 163.
t Praelect. p. 94.
X Retz Annales, iv.
* L'Art de guerin les Maladies Veneriennes, &c, 
SANGUINEOUS FUNCTION.
                        SPECIES  I.

                    LUES  SYPHILIS.



tiLCERS ON THE GENITALS CIRCULAR, UNGRANULATING, THICKENED AT THE
  EDGE ; THOSE OF  THE THROAT  DEEP AND  RAGGED ; SYMPTOMS  UNI-
  FORM IN  THEIR PROGRESS ;  YIELDING TO A COURSE OF MERCURY ; NOT
  KNOWN TO YIELD  SPONTANEOUSLY.

The vulgar term for the ulcers  is Chancres, and the  vulgar name
for the disease is Pox, formerly  Great-Pox* as contradistinguished
from variola or small-pox, on account of the larger size of its blotch-
es.   It was also very generally called French Pox, as being suppos-
ed 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 Fracasta-
rio about the close of the fifteenth century, from the Greek <rv and
pxtm, importing " mutual love ;" for such is the title by which  he
has designated his celebrated and very elegant poem upon this very
 ineleganj; subject.
   There is an equal uncertainty as to the quarter in which the dis-
 ease originated.   It is usually ascribed to  the American continent,
 and believed to have been imported into  Europe by the crews of
 Columbus on his  first or second  return home in 1493 and 1496; a
 belief, however, which seems to be altogether without foundation,
 for at the period even of the  first return of this celebrated circum-
navigator in March 1493, it seems to have  preceded this return by
 some weeks; since on his  reaching Seville in the ensuing month of
 April, in order to join the  Spanish army, it had already arisen and
 was spread over Auvergne, Lombardy, and various other parts of Ita-
 ly ;  as, in the course of the summer months, it was observed in Sax-
 ony, Brandenburg, Brunswick,  Mecklenburg, and especially Stras-
 burg, as all the German writers concur in admitting ;t while Fracas-
 torio, who was an  eye-witness of the entire progress of the disease,
 and from his high  medical  reputation, and  residence almost on  the
 spot of its first appearance, more largely engaged  in the cure of it
 than any physician of his  day, asserts  that it was even ravaging a
 considerable part of Asia and Africa as  well as of Europe : " Euro-
 pam," says he, " fere omnem, Asia? vero, atque Aphricae, partem
  * Da Henry, La Methode curatoire de  la Makulie  Venerienne, vulgairement
appellee la Grosse Verole, &c.  Paris, 8vo. 1SS2.
  t See especially Meiner, Sitten des mittel alten.—Stumf, Schweitzer Chronick.
Lib. XIII.—Stettler,  Schweitzer Chronick, Lib. vii.—Sprengel, Geschichte der
Arueykunde, Theil. u 
550
HiEMATlCA.
[CL. II1.-OR. IV.
 non parvam  occupavit."*   The  writer  proceeds to  notice  the
 dispute that was then hotly engaged in  as well concerning the na-
 ture as the origin  of the disease, and again expresses his disbelief in
 its having been imported from America  by the crews of Columbus.
 On this account, he feels himself at liberty to  give it a very early
 origin in his poem upon the subject, and describes his fictitious hero
 Syphilus as having brought down the disease upon  himself and the
 world at large, as  a curse for having insulted Apollo, while tending
 the flocks of king  Alcithous.

              Protinus illuvies terris ignota profanis
              Exoritur :  primus, regi qui, sanguine fuso,
              Instituit divina, sacrasque in montibus aras,
              Syphiltts ; ostendit turpes per corpus achores,
              Insomnes primus noctes, convulsaque membra
              Seusit, et a priino traxit cognomina morbus ;
              Syphilidemq,ce ab eo labem dixfere coloni.

  One of the earliest German writers  who ascribed the disease to
the return of Columbus is Leonard Schmauss, a physician  of Stras-
burg, whose works were published in  1518 ; but neither his history
nor his  arguments  are in any degree satisfactory: while his coun-
tryman  Matern Berlen,  a clergyman of Ruffach, and an eye-witness
of the disease on its first appearance, assigns  it a very different ori-
gin ; and in  his history of the Italian expedition of Charles VIII. de
clares it to have been a punishment inflicted by the Almighty on this
monarch and his subjects, in consequence of his  having carried off
the Duchess Anne  of Bretagne from  the Emperor Maximilian, to
whom she had been betrothed.
  Among the  Spanish writers, there are  two chiefly who ascribe
the origin of syphilis to  an American source ; while others, by their
silence  upon  the subject when detailing the particulars of the return
of Columbus, give  sufficient evidence that  they disbelieved there-
port.   Of the  two  who thus contributed to spread it, one of  them,
Goncalvo Hernandez de Oviedo, affirms  that it was conveyed into
Italy by Cordova's fleet, which, however, did not  arrive in  Italy
(Messina) till  May 24, 1495, and consequently not till two years af-
ter the  disease had existed there.  The  other is Sapelveda, who, in
a history of America, written in a good Latin style, towards the mid-
dle of the sixteenth century, roundly asserts that " ex Barbaricarum
mulierum consuetudine Hispani morbum  contraxerunt."  But as this
writer does not, like  his contemporary Francastorio, enter into the
particulars of the controversy, his  assertion can go no farther than
to the weight of his own individual opinion in a controverted case.
  Amongst those who have  been most  full in their  accounts of the
 voyages of. Columbus  and the  discovery of America, we may cer-
tainly reckon  Antonio de Herrera.   He  fixes the return of Colum-
bus at the period above specified ; and is  very particular in detail-
 ing the order sent to Lisbon to him, on  the moment of his arrival,
* De contagiosis morbis. 
GE. VI.-SP. I.]        SANGUINEOUS  FUNCTION.             551

to follow the Spanish court to Barcelona, to which city it was then
removed ; the highly honourable reception the circumnavigator re-
cTved;  he preparations which were immediately made for his se-
cond voyage ; the speed with  which  these  preparations
compnE   'and trfe instructions given to him  on  the  o.casiom
Yet not a hint is added that his crews were unhealthy, that fte new
recruits had any dread of the  plague, to wtoc»^^
home  thev must have known they were about to be exposed,  nor
^sfogte^trucSon to be provident of their health it}*ȣ*ǣ
He took leave of the royal pair with every mark of..d^^he
whole court accompanying him to his house, as well at the  time as
when he quitted Barcelona.   « Despiddse,"  says  Herrera,   de. los
Reyes, y aquel dia le acompand  toda la Corte de palacio a su casa, y
 tambien  quando salid de  Barcelona."*
   Linnets stands alone in  arranging syphilis as an exanthem, along
 with small-pox and measles.   He thought himself justified from the
 fever which occasionally accompanies, the copper-coloured spots on
 the skin, in an advanced stage of its secondary symptoms :  or per-
 haps  from  the fever which,  on  the first appearance of the disease
 unquestionably accompanied  it, and uniformly preceded  the erup-
 tions.  For it is an extraordinary fact, to which  all the contempo-
 raneous writers bear witness, that syphilis, when it first broke forth
 upon the world, and, indeed,  as it is described in Fracastono s poem,
 was  not only  called the plague, but was, in truth,  a specific  fever
 attended with most violent putrid symptoms, together with carbun-
 cles,  buboes and  other  glandular  abscesses,  which discharged a
 malignant sanies, often fatal,  and even, when recovered from, leav-
 ing the most melancholy marks of its ravages.
    And hence,  in many places, the infected were as much exiled from
 the community by a line of circumvallation  drawn around them, as
 in the case of plague.  In Scotland, indeed, they were strictly pro-
 hibited  all  medical  assistance, and inhumanly left to the effects ot
  their own licentiousness.  For Mr. Arnot gives the copy of an order
  from the privy-council of Edinburgh, which equa ly banished to the
  island of Inch-Keith those who were  affected with the disease, and
  those who undertook to cure it.t
    By degrees, however,  the disorder appears  to  have  assumed a
  chronic form, and at length so far changed its nature, as  to make its
  attack without fever, and to  remain local  except from absorption.
  It seems still,  indeed,  to be continuing its course  of amelioration,
  notwithstanding the assertion of Dr. Schwediauer,! that it has not
  assumed a more mitigated character at present than in former times;
  for very severe cases are now  much rarer, not only in private practice
  but  even in public hospitals, than they were thirty or forty years
  *go._____________________

         * Hist. Gen. de las Indias occidentales, Decad. i. L. Li. C. v.
         t History of Edinburgh, by Hugo Arnot, Esq.  4to. 1789.
         t Beobachtungen, Sic. p.  172. 
552
H£MATtCA.
[CL. IlI.-OR. IV.
   It is possible that this change may have  been produced by two
causes; firstly by the virus  wearing out its  own strength and be-
coming milder as it descends to different individuals and generations,
and has to cope with the force of sound  constitutions, and, perhaps
also, with a perpetual  instinctive power or  vis medicatrix naturae,
constantly labouring to subdue it: of which we shall hereafter have
occasion to offer other examples than the present.  And secondly,
it is also highly probable that the frequent  and, indeed, universal
use of mercury for its extermination has succeeded,  as a specific, in
Softening its violence, in the same  manner as we know the virus of
cow-pox  succeeds in giving a milder character to small-pox even
where it does not altogether answer as a prophylactic.
  Syphilis  shows itself under two distinct sets of symptoms, local
and constitutional, the latter of which is commonly,  but not always,
a sequel of the former.
  In which way soever it is produced it is usually by means of im-
pure coition; though we shall have occasion to show presently that
syphilitic matter coming in  contact with any part of the surface of
the body where it is capable of burrowing and meeting with a little
mucus, sweat, or, perhaps, any other natural secretion, is capable of
assimilating it to its own nature, and hence  of introducing the dis-
ease into the system by absorption ; and consequently  without any
breach of  surface.   And hence,  as other  parts than  the  sexual
organs may be a medium of communication,  no local symptoms may
in some instances ensue, and the constitutional signs be the  first to
manifest themselves.
  The earliest ordinary mark,  however, that infection has taken
place, is the appearance of one  or  more minute pimples, of a pecu-
liar kind w^ich are called chancres; having a hard inflamed base,
of a pale red hue,  and an irritable apex, at which  it opens  with a
small eye-let, becomes ulcerated, and discharges a small  portion of
limpid virus, that produces fresh chancres wherever it spreads.   In
the common  mode of infection the chancre shows itself on the pre-
puce, glans,  and orifice of the urethra in men, and  about the labia,
nymphae, clytoris,  and  lowermost part of the vagina  in women.
This  mark sometimes  appears  as early as the third or fourth day
after coition, more generally,  however, a few days later;  and in
some instances, where the cutaneous absorbents possess little irrita-
bility, not till a lapse of several  weeks.   The chancre  occasionally
continues blind, and degenerates  into  a hard  and  irritable wart.
with which the genitals are  frequently studded, sometimes as low
down as the anus.
   Another  local symptom is the formation of a bubo in one or both
groins, evidently produced by an absorption  of* the virus first depo-
sited, or, as is more commonly the case, generated in the ulcerated
chancre communicated to the lymphatics, and  hence to the inguinal
glands, which in consequence becomes inllamed and tumefied.  The
tumour, when first perceived, is small,  but hard, fixed and diffused.
with a somewhat  obtuse pain.  It enlarges gradually,  and becomes 
GE. VI.-SP.  I.]     SANGUINEOUS FUNCTION.               553

more  acutely painful, so as to render walking  troublesome ;  and if
not opened by the lancet, generally bursts by the time it has reach
ed the size  of a pullet's egg, and discharges a copious quantity of
pus from a single hollow.   In a few instances, the suppurative in
flammation does not follow, and the tumour as it augments acquires
a schirrhous induration.
  Sometimes, also, the  inflammation extends  by  sympathy to the
spermatic chord, which is inflamed and rigid  through a great part
of its  course, while the testes themselves are tender and considera-
bly swoln.
   And occasionally from sympathy also, or an  entrance of a part of
the received virus into the urethra, its  mucous membrane becomes
inflamed and pours forth a considerable  secretion of pus or purulent
mucus, resembling that of a blennorrhoea, or gonorrhoea as it is com-
monly called, or the purulent discharge from the eyes in purulent
opthalmy.
   This was  at one time mistaken for a  genuine gonorrhoeayind the
two diseases were  very generally regarded as only differennmodifi-
cations  of one and the same species.   And some  practitioners con-
tinue  to be of the same opinion  still, notwithstanding all the facts
that have been adduced in proof of their  being  distinct maladies
produced by distinct kinds of contagion.  The local symptoms of
syphilis, chancres,  and buboes are perpetually occurring without
gonorrhoea,  and gonorrhoea without chancres and buboes.  Insomuch,
that there are not wanting practitioners who affirm that they never
occur together unless the  two venoms are received simultaneously.
And there is no doubt that this assertion is true  in regard to a ge-
nuine gonorrhoea; but from the  cause  already stated, a large flow
of pus or purulent matter, and a  general irritation and enlargement
of the body  of the penis,  in appearance  strongly resembling the
symptoms of a genuine  gonorrhoea,  sometimes coincide with the
primary signs of a syphilis, of which a very marked case occurred to
me only a few weeks ago which  I showed to an eminent surgeon of
this metropolis who  had antecedently  been incredulous upon this
point.  But  the clearest and most incontrovertible proof of distinc-
tion between the two diseases is that in no instance whatever has a
simple gonorrhoea, unconnected with bubo or chancre, produced those
secondary or constitutional symptoms to  which the proper local signs
of syphilis are sure to lead if not corrected in their progress.
   These symptoms are a peculiar affection of the  mucous glands of
the fauces and mouth, which eliminate  syphilitic poison along with
their  prop'er secretion, whence the tonsils, uvula, palate and tongue,
progressively become sore and  ulcerated,  the voice is rendered
hoarse,  and  the swallowing difficult.  The  ulcers about the fauces
are of a distinctive character, being foul and rugged,  with an exca-
vated centre covered with a brown or whitish siough,  and surround-
ed with a hard, red, elevated and erethematous outline.
  The mucous  membrane of the conjunctive tunic of the  eye*
next suffers in the same way, and displays an inflamed surface with
  vol. h.             70 
551
ILEMATICA*
[CL. I1I.-0R. IV.
ulcerations on the eye-lids and angles of the eyes.   The skin is, in
various parts, covered over with copper-coloured spots, which at first
desquammate in scurfs, afterwards in scales, and still later in scabs;
each of which leaves a foul ulcer that gradually grows deeper, and
discharges an  offensive and acrimonious fluid.
  As the disease advances,  irregular pains shoot through the limbs,
and are felt so severely at night as to prevent sleep.  By degrees
they strike into the bones, which  become diseased, and in many
places  swell into nodes, which  at length  grow carious:  while the
ulcerations about the fauces spread at the same time, or even before
this, to the adjacent bones of the  palate and nostrils which are
gradually  eroded and carried away;  so that the speech is rendered
nasal and  imperfect, and the nostrils are flattened to the level of
the cheeks.
  Finally, the countenance grows sallow,  the  hair falls off, the
appetite is lost, the strength decays, and a low hectic preys  upon
the system, and at length destroys it.
  it isltot easy to say how long the  matter of syphilis,  when  once
communicated, may remain limited to   the  local symptoms  of
chancres or buboes, or continue inert in the system where no  local
symptoms  have taken place ;  or what period must  intervene before
a patient may  be pronounced safe after having exposed  himself to
contamination. We have  already seen that the primary, or  local
signs generally manifest  themselves within four or five days; and,
where  the constitution  has  become infected without them, we  have
reason  to expect the appearance  of the  secondary symptoms  soon
after three weeks,  or from this time to  six months: and, if this
latter interval have passed without the slightest manifestation of
mischief locally or  generally,  we have little reason to fear for the
issue.  It  has  been said, however, that the poison has lurked unper-
ceiVed for several years: yet it is  rarely that such an assertion is
made except  for the  purpose of excusing some  fresh  infection.
I should,  indeed, have been disposed to  think  it had never  been
made otherwise but that Dr. Hahnemann has referred to an instance
or two to the contrary in  which  he places  full confidence ;* and
particularly that the late Mr. Hey of Leeds, whose authority is in-
disputable, has offered it as his opinion, formed from a  variety of
cases that had occurred  to him during  an extensive practice of
nearly three score years, that a man may communicate the disease
after all its symptoms have been removed and  he is judged to be in
perfect health ; and that a  mother who has been once affected may
convey it, notwithstanding  an apparent cure, to two, three,  or four
children in succession,  each of whom he supposes  will have it in a
milder form than the preceding one; as though it were gradually
ceasing in the constitution, though it still continued to show some
degree of activity.!
  * Hnhneiminn, Unterricht fur Wundarzte liber die Venerischen Krankheiten.
8vo. Ljips. 1789.
  t Facts illustrating the effects of the Venereal Disease.  By William Hey, Esq.
F.R.S. 1816. 
GE. IV.-SP. I.]      SANGUINEOUS  FUNCTION.              555

  It is obvious, however, that in syphilis, as in various other diseases
produced by the absorption of specific virus, different  constitutions
are differently affected, and that some are far more susceptible of
the morbid action than others.  In  many instances, it is received by
simple contact alone and through an unbroken skin.   It  is generally,
perhaps, thus received in the ordinary course of connexion ; but still
more evidently  thus in other cases, and by other organs; for it has
been  very frequently caught by sucking the nipple of an infected
wet-nurse ; by infected saliva communicated in kissing; by drinking
out of a cup that has previously been used by a syphilitic patient ;*
and it is said to have been produced by receiving infected breath,t
and  lying  in  a  bed which had been antecedently occupied by a
person labouring  under  the  disease :J  hi  s<>me  of which  cases,
however, it seems necessary to suppose  the existence of a cut or
crack or some other breach of surface in the  skin, and particularly
about the lips, with which the syphilitic  virus  must have come into
union.  And it is hence easy to conceive how much more readily it
may  be communicated by  the insertion of an  exotic  tooth,§ by
bleeding or scarification with an infected lancet,||  or by the attend-
ance  of ans infected midwife,1T who has sometimes given the com-
plaint both to the mother and the  child.
   A  very  melancholy instance of infection is related by Dr. Barry
of Cork, communicated by a woman who was in the habit of draw-
ing the breasts of puerperal patients, and who, upon  examination,
was found  to  have chancres  on the lips  and roof of her mouth ;
probably caught from some impure person in the course of her
vocation.   From the numerous engagements  of this  woman, the
disease had spread very widely ; and the rapidity of its progress was
as striking as the manner  of  its  communication.   " The nipple,11
says Dr. Barry, " first became lightly inflamed, which soon produced
an excoriation, with a discharge of a thin liquor:  from whence red
spreading  pustules were  dispersed  round it  and gradually  spread
over the breast,  and,  where the  poison  remained  uncorrected,
produced ulcers.  The pudenda soon after became inflamed, with
a violent itching, which terminated  in chancres that were attended
with only  a small discharge ;  and,  in a short time after, pustules
were spread over the whole body.  It finished this course, with all
these symptoms, in the  space of three months^  The disorder made
a quick and rapid progress in those  who firsff-eceived it, they not
being apt to  suspect an  infectilh of this  nature in their circum-
stances.  The  husbands  of several had chancres, which quickly
  * Reid, Diseases of the Army, &c.  Gruner, die Venerische Austehung durcl\
gemeinschafftlische Trinkgeschirre.  Waissenfels, 1787.               •
  t Reid, Diseases of the Army, &c.
  X Horstius, opp. n. p. 315.
  f;  Watson, Medical Transaction.  Vol. in. p. 325.
  ||  Girtanner, die Venpriscjien IJrankheiten, &c. p. 165.
  * Act. Nat. Cur. Vol. vn. Obs. 75. Vol. IX. Obs. 94. 
556                      HJEMATICA.          [CL. III.-OR. IV.

communicated the poison and produced ulcers in the mouth, and
red spreading pustules on the body.  But such of them escaped who
had timely notice of the nature  of the disease before the pudenda
were affected.  Some infants received it from their mothers, and to
the greatest part of them it was fatal.'1*
  Where a wet-nurse and the  infant she suckles  are both affected,
and  there is a  doubt which  has communicated  it to the  other,
collateral circumstances will assist us much:  but where the  one, as
is usually the case, has constitutional symptoms, and the other only
local, the  former  must have  had the disease longest, and  conse-
quently have been the sodfce of contamination.
  Such,  however,  is the  unsusceptibihty of some  idiosyncrasies,
that the  matter of syphilis, like that of small-pox, seems to have no
effect upon them,  and they are  proof against its  activity.   I once
knew a  young physician who finding  himself to be thus naturally
protected, fearlessly, and  for the  sake  of  experiment,  associated
himself  with females in  the  rankest state of  the  disease, and
escaped in every instance.  In like manner Schenckt gives us a case
of an infant rendered syphilitic through a diseased  father, while the
mother  remained unaffected; and Mauriceau and other writers,
give  cases of infants which have been fortunate enough to avoid
infection though born  of syphilitic  mothers :| while Pallas asserts
that the Ostiacks have a general  immunity from the disease under
whatever form it offers itself.§
  The medicines which have been chiefly had recourse to, or have
been found most  serviceable in  curing  syphilis  or  arresting  its
progress, are narcotics, diluent diaphoretics, diuretics, drastic pur-
gatives and those which introduce  a large portion of oxygene into
the system ; practitioners having directed their attention at different
times  to rendering  the vascular  fibres inirritable  to the  specific
acrimony of the disease, to expelling it by some of the emunctories
opening externally, or to  dulcifying it  by a chemical combination.
   Of the narcotics, recourse has been chiefly had to  opium, conium,
solanum, and bella-donna, manifestly  upon  the principle of their
being sedatives, and  hence rendering the system  inirritable to the
syphilitic virus.  This some of them accomplish in a very consider-
able  and desirable degree ; and particularly opium  which has been
mostly trusted to, anfftried upon a wider scale than  any of the rest.
It moderates and alleviates every  symptom; and, from a cause not
well ascertained, may be  taken in%ery large doses with less incon-
venience in syphilis than in almost any other disease.  From "its
palliative effects it has been supposed by many practitioners capable
of producing a radical cure ; and numerous accounts to this purpose
have .been published by those  whose judgments have been  unduly

    * Edin. Med. Essays, Vol. in. Art. xxi. p. 297.
    t Observ. Lib. vi. N. 21.
    X Mauriceau, n. p. 100. 377.  Eph. Nat. Cur. Cent. hi. iv. Obs. IS.
    J Reisen, in. p. 50. 
GE. IV.-SP. I.]      SANGUINEOUS FUNCTION.              557

prejudiced in its favour.  On these  accounts it  is not necessary to
enlarge: they have been  long  before the world, and have called
forth other trials which  have not  proved equally successful.  Nar-
cotics in general, and opium beyond the rest, add considerably to
the efficacy of other  means, and particularly  of mercury;  but of
themselves they are not competent to remove  the complaint, and
consequently are not to be depended upon.
  The hst of warm and diluent diaphoretics that have been employed
as remedies in syphilis are very extensive ; but it may be sufficient
to enumerate the following:  mezereon, guiacum, sarsaparilla, sapo-
naria,  bardana, smilax, and  one  or two  species  of asclepias or
swallow-wort.
  All these are  supposed to be serviceable by exciting a determi-
nation to the skin,  and throwing off the syphilitic poison, as various
other poisons are  thrown off, from the surface: and in  very warm
climates many of them are  said to operate a radical  cure;  though
the statements to this  effect are rarely such as we can depend upon.
Some of them, moreover, as the saponaria or soap-wort, and smilax
or china-root, possess  a viscid or unctuous principle, which has been
supposed ofuse in obtunding the acrimony of the poison, and thus
blunting  its effects even  before  it is discharged from the  body.
The soap-wort has the advantage of being found in the hedges of
our own country.
   'Bhey have all had  their day, and the only one at present in much
request is sarsaparilla, of the actual amount of whose virtues it is
difficult to speak with precision.   Like the lobelia syphilitica or blue
cardinal-flower,  which is a  purgative plant, it owes  its earliest
reputation  to  the  American tribes; and  when  first  imported into
Europe by the Spaniards about  the year 1563,  it had the character
of being a specific for the  venereal complaint.  From being ex-
tolled, however, too highly,  for it has never fulfilled  this character
in the old world, it has since sunk, like many other useful medi-
cines, into a  very unmerited contempt, insomuch  that  Dr.  Cullen
allows but eight lines to its history and qualities, in  the course of
which he tells us that if he were to consult his own experience, he
would not give it  a place in the Materia Medica, as he has never
found  it  an effectual  medicine  in  syphilis or any other disease.*
The London College,  however, have  evinced  a different  opinion,
for they have adopted it under various forms: and Dr. J. Thomson,
of the Depot Hospital, Edinburgh Castle,  has been so highly satis-
fied  with its  antisyphilitic  powers, that  he has for some  years
relinquished the use of mercury altogether in favour of a new mode
of practice, which consists chiefly in the employment of sarsaparilla.1
Upon a very large  scale he has met with very great success ; though
he candidly acknowledges that the secondary s}rmptoms  of the
disease have required a longer time to be overcome under the new
* Mat. Med. Part n. Chap. v. p. 200.
t  Edinb. Med. and Sur?. Journ. No. i.iii. p. 84. 
558
HjEMATICA.
[CL. HI.-OR. IV.
treatment than they would  under a mercurial.   Its fair pretensions
appear to be those of a mild stimulant and diaphoretic.  It is hence
in many cases a useful auxiliary to mercury : but I have chiefly found
it succeed in chronic cases  where the constitution  has been  broken
down perhaps equally beneath a long domination of the disease and
a protracted, and apparently  inefficient, mercurial process.   In
eonnexion with a milk diet and  country air, and with a total aban-
donment of mercury, I have here often found it of essential import-
ance, and have  seen  an  incipient hectic fall before a free use of it
in a week.  Its best form is the old one of the  decoction  of the
woods.
  The syphilitic poison has also been often attempted to be thrown
out of the body by exciting the  excretories of some other organ
than those of the skin or in conjunction with them.   Thus the flam-
mula Jovis,  or upright traveller's joy, the clematis recta of Linneus,
which acts powerfully both on the surface and on  the  kidneys,  is
said to have been employed with great  advantage, and was  at one
time in high and extensive estimation.  It was  given in the form
of an infusion of tbe'leaves, and Dr. Stoerck,  with his usual liber-
ality, assigns it  an extravagant praise, informing us that it effectual-
ly subdues  all  the  secondary symptoms of inveterate head-aches,
bone-pains,  nodes, ulcerations  of the throat,  and cutaneous erup-
tions.*
  The lobelia syphilitica of the American Indians has a still faflrer
claim to  notice.   It is a drastic purgative, uniting something of the
stimulant and  narcotic  powers  of tobacco, to which it has  some
resemblance in its taste.  In  the simple life and inirritating diet  of
the American tribes, it is possible that it may  have  proved as suc-
cessful as it is stated to have done ; but it has  completely failed in
Europe.
  Of the antisyphilitics, whose influence seems  to depend on their
being loaded with oxygene, the principal  are the mineral acids, and
the metallic oxydes.
  Of the first, the nitric has chiefly been made a subject of  experi-
ment in our own country, though the sulphuric has been employed
abroad.!   How far it exercises a chemical power upon  the syphi-
litic virus, and forms a new and blander substance with it, is uncer-
tain.  Its general effects are, as we might expect them to be, tonic
and sedative ; whence the  appetite  is increased, a greater rigidity
or firmness is given to the living fibre, and a greater density to the
coagulable lymph: the action of the bowels and even of the blad-
der being diminished.  Besides these, it  has a particular effect on
the mouth approaching to  that of ptyalism,  for  the gums  are ren-
dered slightly sore, the mouth and tongue become moist, and in In-
dia and other warm climates a real salivation is said to ensue.  Un-
  *■  Libellus quo demonstratur herbam veteribus dictam flamtnulam Jovis possa
tuto exhiberi. Vienn. 1769.
t Crato, Epist. v. p. 293. 
GE. 1V.-SP.  1.]      SANGUINEOUS FUNCTION.               559

der this change the syphilitic symptoms assume a better appearance,
and especially those that belong to the primary  set:  but we  have
no decided case in which a perfect cure has been  accomplished in
our own country ; though Dr. Scott affirms that in India this has been
common.  The acid he was in the habit of employing was a direct
aqua regia as already noticed in the treatment of jaundice ;* and with
the internal use of  this, he combined that of the acid bath as  there
also particularly specified.   His object was to effect a cure without
incurring any of the evils so frequent upon a  mercurial course;
and to this object the proposed plan has, in his opinion,  given  com-
plete success.  It would  have been happy for the world if this suc-
cess had  been permanent  and universal; but  the plan has  since
fallen in its reputation not much less in India than  in Europe.
  The metallic oxydes have offered a  large field  for experiment;
and almost all the metals have been had recourse to  in  rotation, as
copper, iron, antimony, mercury, arsenic,  and even gold.
  The pretensions  of  arsenic are certainly considerable :  it forme
the ordinary medicine employed in syphilis by the cabirajas or native
Indian physicians, who depend upon it as a specific.  They give it in
the form of white  arsenic in combination with black-pepper, as we
shall notice more at large when treating of elephantiasis, for which
also it is esteemed a powerful remedy.   The only  auxiliary is  a ca-
thartic of manna dissolved in a decoction of nympha? a nelumbo.
  Of the  effects of any of the  preparations of gold we know but
little.  Many of them  were in high repute formerly  as  a cure for
various cachexies, and  are said to  have been used with  success in
syphilis.f   They  have since been repeated in France, and are re-
ported to  be entitled to all the  distinction they  have at any  time
attained;  but as a train of experiments upon this subject is still in
hand we may hope  for  more'certain information in  a short time.J
  Antimony, and perhaps a few other metals are useful auxiliaries;
but, in fact,  the only metal, and I  may  add the  only  medicine,  on
which we can confidently rely for a perfect cure of syphilis in all
its stages in our own climate, is mercury.
  This has been tried from an early period in almost every variety
of preparation ; and, provided a sufficiency of it is introduced into the
system, in every variety  it has  been  found to succeed: so. that in
the present day the  peculiar form is regarded of less importance than
on it? first use ; though we may observe that it seems to be  most
rapidly efficacious in those forms that introduce the largest  propor-
tion of oxygene into the system.  And  as  it operates chiefly, like
most other medicines, through the medium of circulation, when it
once becomes mixt  with the current of the blood it is  equally effi-
  * Vol. I. Cl. I. Old. 11. Gen. I. p. 257.
  t Argricola, Comment, in Pappium, Num. 1643.—Ochmcn, Feldchirurgus, 8vo.
Fr. and Leips. 1750.
  X See the Report of A. S. Duportal. M. D. and Th. Pelletier, Apoth. Annalcs de
Chemic. Tom. txxvin. p. 38. 
560                     HiEMATICA.            [ct. III.-OR. IV.

cient in the cure of a recent chancre, and a chronic ulceration of
the throat.
  Mercury is an universal stimulant, and increases the action ol all
the secretories at one and the same time ; for it operates simulta-
neously on the intestines, the skin, the salivary glands, and even the
bladder; though it displays itself chiefly by its action on the saliva-
ry glands.   It has also, when given in moderate doses, considerable
pretensions to a tonic power,  though this is  overwhelmed by its
stimulant effects when the dose is considerably increased.  It seems
therefore  to unite most  of the virtues  of the  preceding  remedies,
excepting the sedative; and  hence it is greatly  improved  by  the
addition of opium and camphor, which give it the quality it stands
in need of.
  Independently, however, of its combining in  itself  many of the
virtues of the preceding remedies  mercury seems also  to  possess
seme  specific virtue unknown to the rest; for we can associate all
the general qualities by a combination of different medicines with-
out producing the same result.   Mercury, indeed, to  these  general
qualities adds  that of peculiarly  stimulating the  salivary glands,
which the other remedies employed in syphilis do  not at all, or never
in an  equal degree;  but that its specific power as an antitode  does
not depend upon its being a sialogogue is clear, because while it
has sometimes excited salivation  without  effect,  it has at other
times produced a perfect cure without any salivation  whatever, for
in some idiosyncrasies the salivary glands are not affected by its ir-
ritation.
   Dr. Cullen, however, who had a mortal aversion to considering
any medicine in the character of a specific, denies that  mercury is
a specific in syphilis, as he  does also that it is  an attenuant of the
blood  or an antidote to  the disease. It is in vain to  point out to
him its specific influence  upon  the salivary glands, or  its  specific
action upon their mouths; he denies the whole, and contends that
mercury might travel, and perhaps  would travel for ever in  some
other  direction, were it not for  the friendly interposition of the am-
moniacal  salts of the blood, which  he fancies to  have a close  affin-
ity with mercury as they have also with the salivary glands ; in con-
sequence  of which, they take the mercury by the  hand  and intro-
duce  the one stranger to the other :* thus solving the difficulty like
a divinity  in the catastrophe of a drama.  The result of the whole,
in the opinion of Dr. Cullen, is that mercury cures the venereal
disease, not by producing any change in the state of the fluids, but
entirely by giving a stimulus to the excretories at large, by what-
ever  contrivance it reaches them,  and  thus  increasing  the excre-
tions  and  washing out the poison from the body.
   That it does this  is highly probable; but this alone is not  suffi-
cient, for fresh poison is continually forming by  the process of as-
 * Mat. Med. Part. n. Ch. xvn. p. 443—450.—See also the present Work, Vol
I. p. 5!i. 
«3E. VI.-*P. U]
SANGUINEOUS FUNCTION.
561
similation, or the conversion of some part of the fluids it comes in
contact with into its own nature ;  since  if it wore not so,  and  the
minute drop of virus that excited  the disease at first remained with-
out any increment, there can be  no  question that such  a  general
«couring of the system would be unnecessary, and that the ordinary
evacuations would be sufficient to throw it off.   And hence we .have
not only  to carry away the poison that is actually present in the ves-
sels but to prevent the formation  of  new.
   Now it is in this power of prevention that the specific virtue of
mercury seems to consist;  and this it is that renders  it  paramount
to  all other remedies  in  the cure  of syphilis.   It is not only an
evacuant but an antidote.   By what  means, however,  it becomes an
antidote, or exerts its specific power, we know not.  The matter of
a chancre mixed up with a quantity  of  Plenck^ gummy solution of
mercury has been applied to a sound person without occasioning eith-
er a chancre or any other syphilitic symptoms. And it has hence been
supposed that mercury neutralizes the syphilitic virus and produces
a third  and harmless substance.   As it has  been  further supposed
that it is by the disengagement of the oxygene  which the various
preparations of mercury introduce into  the system that this effect is
accomplished.   All this is  ingenious and may be true, but the  evi-
dence does not come home to the  conclusion.  Even the experi-
ment with chancrous matter and the mercurial solution has  not been
-Mjtisfactoriiy performed; and if the  result were as here stated, the
matter while it has no power of assimilating  the solution into its
own nature, as it has the fluids of the human body, may  only have
been rendered inert by simple dilution.
   We have said, that provided a sufficient quantity of mercury be
introduced into the system,  the particular preparation is  of no great
importance. Van Swieten preferred the oxymuriate,  and every one
followed his example.   The calcined mercury  came  next  into po-
pularity  and triumphed over everv other form.  It was the leading
article of most of the secret remedies that were sold for the com-
plaint and especially of Keyseris pills, the receipt for which  was
purchased with great formality by the French government, with an
express  provision not to make it public till the inventor's death.*
These pills, however, which consisted of nothing more than mer-
cury calcined  by a needlessly operose elaboration,  and mixed up
with manna, were found in  many  cases to irritate the bowels even
when united with aromatics and opiates; and hence they gradually
yielded on  the continent to  Plenck's solution,  which still holds a
considerable sway.
   In  our own country, it is now most usual to employ  the mercurial
pill,  or  calomel, either alone or  together with mercurial ointment.
Yet, whatever plan is preferred, much caution is necessary in carrying
it into effect; for the older practitioners who employed larger doses
  * Des Dragees ou Pilules de M. Keyser.  P;'.  Richard de Hautesierck.  Recfl-
nil d'Observations de Medicine des hopitaux Muitair--s. &c. Paris 1766.
  VOL. II.                 71 
S62
HittMATICA.
[CL. HI.-OR. IV'
 did as much  mischief to the constitution by  the antidote as it had
 received by the infection.   If calomel be employed, about two grains
 a day will be sufficient,  guarded when necessary by  a grain of
 opium, and if the ointment be preferred half a drachm of the strong
 mercurial  ointment  may be rubbed in night and morning.   If the
 disease be  not severe or of long standing, it  will not be  necessary,
 with a little  management, to produce salivation,  which in most in-
 stances may be regarded only as a test that the system is thoroughly
 impregnated with the medicine : but in chronic cases we ought not
 to be satisfied without it.
   In all cases of its use, but particularly in cases of salivation, care
 should be taken to avoid cold, and flannel should  be worn next the
 skin; for it is  important that the excretories should harmonize in
 an  increased defluxion.   It is also  of importance that the  diet be
 light and simple, as the pulse is usually accelerated, and, by a stimu-
 lating regimen,  would be so much quickened as  to do serious mis-
 chief.  Mr. Hunter lays no stress upon this point but it ought by no
 means to be neglected.
   If a buboe have  formed in the groin the   mercurial ointment is
 best rubbed in a  little below it, as it would increase the inflamma-
 tion if applied  to the tumour itself.  In about a  week or ten days,
 the mouth  will become slightly sore, when the further use and pro-
 portion of the ointment  or other preparation must be regulated by
 the violence  or duration of the complaint.  Where salivation is de-
 termined upon, the flux  should be suffered to continue  for about a
 month.
  An.injudicious use of mercury, or indeed any use of  it, in highly
irritable habits, will sometimes excite a very  troublesome erythema
that spreads itself in trails or patches over the whole surface; com-
monly however commencing about the  genitals,  and lower limbs.
It is accompanied with a painful tenderness and itching of the skin,
and, as the  erythema meanders onward,  the  trails or patches first
 observed heal as  new ones  make their appearance.  We have al-
ready glanced at  this affection under the vesicular species of ery-
thema.*  Mercury must in this case be desisted from, the bowels be
loosened with some gentle  aperient and the  irritability opposed by
sedative and mild cardiacs as camphor,  guaiacum, and sarsaparilla;
and particularly by the mineral  acids.
* Vol. u. Cl. m. Gen. vi. p. 209. 
«E. VI.-*SP. II.]      SANGUINEOUS FUNCTION.              563


                         SPECIES II.

                  LUES SYPHILODES.

                        Jfcistarti  tyo\\

#LCERS INDETERMINATE IN THEIR CHARACTER ;  SYMPTOMS  IRREGULAR I&
  THEIR  APPEARANCE ;  USUALLY  YIELDING  SPONTANEOUSLY ; VARIOUSLY
  AFFECTED BY A COURSE OF MERCURY.

I have already observed  at the opening of the present  genus that
the species before us is designed to include a multiplicity  of  affec-
tions  which  in  many of their signs have a close resemblance to
syphilis, but differ from it in the progress of the symptoms as well
as in the means  that are necessary for a cure.
  Such affections are of high antiquity, and some of them appear to
be glanced at in  the sacred records.   By Celsus the subject  is touch-
ed  upon scientifically:  it has been taken up in modern times by
Mr. Hunter with that spirit of inquiry which peculiarly distinguish-
ed him,* and has^since been  pursued by Mr. Abernethy with a
kindred  comprehension  and genius.f   The  subject,  however, is
still in its embryo.  Mr.  Hunter considered his own remarks rather
as hints for others to prosecute  than as a complete  account  of it.
And though Mr.  Abernethy has accumulated facts and cases, and ably
illustrated them  with observations  that sufficiently establish  these
hints, and give something of a body to the outline, we are still in
want of distinctive  characters, and  cannot  determine  with any de-
gree of accuracy whether the wide group of complaints  that fall
within the present range of contemplation, are  mere varieties of a
common species produced by a common poison, or distinct species
dependent upon  distinct poisons, as discriminate from each other as
all of* them are from proper syphilis.
  It was regarded  by Mr. Hunter  as a  pathognomic character of
syphilis, first that it never ceases spontaneously; secondly,  that it is
uniform and progressive in its symptoms; and thirdly, that itis only
to be cured by mercury.
  How far the last position may admit of such a modification as may
leave it open  to occasional exceptions in other  climates,  it is n'ot
worth while to inquire.   In our own, the whole of these dicta stand
upon a rock of facts progressively  accumulating and  confirmed by
every  day's  experience.  And  the  family of complaints  included
under the name  of bastard-pox,  or  pseudo-syphilitic  disease are in
direct contradistinction to all of them; for they are perpetually giv-
ing proofs of  a spontaneous  cessation ;  they are irregular and de-

     * Treatise on the Venereal Disease.
     + Surgical Observations qn Diseases resembling Syphilis. Lond. 1810. 
564
HjfcMATICA.
[CL. itl.-OR. IV
sultory in  their symptoms;  seldom require a mercurial  treatment,
and are often exasperated by it.
  In illustration of these remarks, 1 might refer to the observations'
of those who have been attentive to  the subject on a large scale;
but I refer more  particulaily  to the collection of cases which Mr.
Abernethy has printed in the work already adverted to.
  The disease ordinarily commences with local symptoms, though
not always: but the local symptoms have a less resemblance to those
of genuine syphilis than the constitutional by which they are suc-
ceeded.  A few  foul and highly  irritable sores are unexpectedly
discovered on the genitals, commonly larger than chancres, and less
thickened  and indurated, about the size  of a six-pence, and frequent-
ly sprouting with  fungous  granulations.  Rarely, but very rarely,
they have the guise  of  a true chancre: so rarely,  indeed, that of
the twenty cases contained in Mr. Abernethy's book, the fifth is the
only one that answers to this description.   These  are  sometimes
succeeded by buboes; and sometimes not.  And where buboes  take
the lead they run their course  more rapidly,  and with more violent
inflammation than in  the true disease, and spread to  a greater num-
ber of circumjacent glands.  These often heal by the ordinary means
without mercury, or  constitutional symptoms of any kind.   But not
unfrequently, in a few  weeks or months they fare followed  by a
soreness and ulceration of  the tonsils,  copper-coloured  spots  over
the body,  and nodes or swellings of the periosteum in various bones;
and sometimes these  symptoms change  their order of succession, or
appear single.
  In a few instances, the constitutional symptoms take the lead and
the local  follow, of which  Mr  Abernethy's  fourth  case affords an
example.   The patient  here perceived, first of all, a small ulcer on
the breast near the nipple,  after having suckled a nurse-child about
four months.  It was of the size and shape of  an almond, and was
ascribed to the child's having a sore nose and lips.   A gland in the
axilla  soon  swelled  and subsided: but in  about two  months the
patient had a severe  febrile attack  accompanied with a sore throat;
from this  she soon recovered, but had  shortly  afterwards a copper-
coloured eruption  scattered over the body; and  upon the disappear-
ance of this, white blisters about the pudenda which gave her pain
in walking.   About a week afterwards  her husband found a sore on
the penis  covered by a black scab, of about the size of a sixpence,
with a base neither  hard nor thick, but with the surrounding skin
much  inflamed.   Another  formed  in the course of the lymphatics
towards the groin: the inguinal glands enlarged, and one of" them
suppurated ;  and an eruption of a papulous erythema, ushered by a
few febrile symptoms,  followed in about three weeks.  The sores
were twice touched with  lunar caustic, and, as well as the  bubo,
we're afterwards washed with calomel in lime-water: they gradual-
ly healed.  Both patients recovered, the wife  with little assistance
from mercury, having taken only a few compound calomel pills with
small doses of nitric acid;  the husband  without  mercury altogether,^ 
GE.TI.HSP.il.]      SANGUINEOUS  FUNCTION.  .            56S

except  that a dose of calomel was once administered with  other
aperient drugs as a purge.
   In all these cases, we  meet with a virus that seems to be more
active and irritating than that of genuine syphilis, but which, while
it pursues, though with much irregularity, the same  general path,
runs through its course much quicker, and is more effectually coped
with  by the natural strength, or remedial instinct of the constitu-
tion.  And hence, all that we are here called upon to do in the way
of treatment is,  to  support the general  vigour,  and second  the in-
stinctive  effort.  This is best to be accomplished by tonics and
gentle stimulants, and,  where necessary,  by sedatives.   The mineral
acids are the best means of  supplying the first intention;  camphor,
the decoction of the woods, and the  compound  calomel pill, where
small doses  of mercury do not  irritate,  the second; and opium the
third : though to this  last it will rarely be  necessary to have re-
course at all.
   The distinction between  these affections and  genuine  syphilis is
frequently difficult, but of importance : since, as a full use of mercu-
ry seldom seems to do good, and  often does serious mischief in the
former, such a plan has a chance of  overwhelming the constitution
with  a second disorder instead of freeing it from a first.
   To this family of maladies we are probably to refer the disease,
which, for  a century  or two, has been known  in Scotland by the
name of sibbens  or  sivens, literally rubula, or rasp-berry eruption:
and which seems to he a variety of lues rendered hybrid by passing
through  a constitution  already contaminated with genuine rubula  or
yaws.  The locai symptoms have a much nearer resemblance  to
those of bastard-pox than of  genuine syphilis, but, in its constitution-
al progress,  after the  ordinary affection of  the  fauces, the disease
has a  tendency to throw  forth,  over the surface,  an eruption of
tubercles which  speedily degenerate into fungous ulcers resembling
yaws, rather than an eruption of  copper-coloured spots :  which tu-
bercles sometimes show themselves  also in  the  throat itself.   The
constitutional disease  spends itself chiefly on Jhe surface,  and the
bones are rarely affected.  With these exceptions we may agree
with Dr. Gilchrist,* and Mr. Hill of Dumfries,!  that it has not a
symptom which  does  not accompany the lues  venerea  (meaning
syphilis J through all Europe; that both are equally infectious; both
only communicated by sexual intercourse or other familiar contact;
and both beneficially treated  by mercury; which, they affirm, is the
only remedy to be depended on.   Mr. Hill  tells  us that  it was in-
troduced into  the vicinity of Dumfries, about the year 1772, " by
some  pocky soldiers, who,  to prevent  their debauching in town,
were  disposed through the neighbouring villages."  Even upon
his own showing, however, a much looser and blander exhibition of
mercury  than is  sufficient for the  cure of a confirmed syphilis, will

     * Account of a very infectious Distemper,  Sic.
     T Cases  in Surgery ; te which is added an Account of the Sibbens. 
566
M^EMATICA.
[CL. IH.-OR. IV.
effect this in sibbens; for he adds that" by the employment of a mild
preparation of this metal he has cured  numbers without confining
them to their houses  even in  frosty or snowy weather."  It is pro-
bable,  therefore, that sibbens might be eradicated by other means
as well; but these gentlemen, notwithstanding the  peculiarity of
many of its symptoms,  regarded it as a genuine syphilis;  and, in
consequence, did not direct their attention  to any other mode of
treatment.
                     GENUS  VII.

                   ELEPHANTIASIS.

                     SSlrjjJianteSfcfii.

Skin thick, livid, rugose, tuberculate ;  insensible to feeling ; eyes
       fierce and staring;  perspiration highly offensive.

The Greeks denominated this disease  elephas of elephantiasis, be-
cause  the skin of persons affected  with it resembles that of the ele-
phant in thickness, ruggedne«s, insensibility, and dark hue.  Thus
applied, therefore, the term  imports elephant-skin : in the same man-
ner as the same national  school denominated  dandriff pityriasis, or
bran-skin,  from  the  skin, under  this  disease resembling  branny
scales; and  another sort  of scaly malady  ichthyiasis, or fish-skin,
from the resemblance of the  skin, when thus affected, to the scales
of fishes.  There are, however,  two  diseases of a very different
kind,  which occur in the translations of the Greek and Arabic wri-
ters under the name of elephas, elephantia, or elephantiasis; that
immediately before us, and the thick leg of Barbadoes and other hot
climates:  and, as  the former of these has also, by many of the Ara-
bian writers, been called  lepra or leprosy,  and especially black le-
prosy, though as  distinct  from genuine leprosy as  it  is from the
thick-leg; and,  as the common term  lepra has been continued in
the translations of such writers, and copied from them by writers of
our own times,  an almost impenetrable confusion has been  thrown
around the whole of these diseases; and they have, even by mo-
dern writers been strangely  huddled together, and contemplated as
mere  modifications of one and the same malady, or as having some
other connection  which does not in reality exist.
   My attention  was particularly  called*to this subject about five or
six years  ago by  an application from Dr. Bateman,  who was then
preparing his work for the press, on Cutaneous Diseases, to assist him
in unravelling it from the thorny maze in which it was at that time
enveloped,  and, as the following letter from him, written in conse-
quence of my acceding to his request, shows the real difficulty of 
GE. VII.]
SANGUINEOUS  FUNCTION.
567
the case, and is highly creditable  to the activity of his mind, the
reader will be obliged to me for introducing it:
   " In order to give you the least trouble possible, in the research
which you were good enough to promise to  make for me this morn-
ing,  I wish to state in a few  words,  the object  of my inquiry.   I be-
lieve the proper tubercular elephantiasis of the Greeks; was called
juzam,  or aljuzam by the old Arabians {dsjuddam and madsjuddam
by the moderns,  according to Niebuhr.)*
   " If so, do the other Arabian  writers  also  designate  the  proper
elephantiasis, by the same appellation ?—For instance, is it used by
Haly Abbas ?T
   " Again, what is the Arabic term applied  to the thick leg  (which
most of the translators call  elephantiasis,  but which the translator of
Haly Abbas, calls elephas, thus distinguishing  it from elephantia ?)—
The thick leg is  described by Haly  Abbas,J by Avicen,§ by Rhases||
and by Avinzoar.lF   The translators of the  other  works in these
places, use the word elephantia^
   " Thus, the proper elephantiasis is called  elephantia by (the trans-
lator of)  Haly  Abbas,  and lepra  by  (the  translators of) Avicen,
Rhases,  and Avinzoar.—And the thick leg is  the  elephas of the for-
mer, and the elephantia of the latter.—My chief inquiry  is, whether
the difference is only among the  translators, or whether there is
likewise a want  of uniformity in the nomenclature of the  original
writers.
   " En  passant, I may observe, that some  farther confusion has
arisen among the translators, respecting another leprous disease,  as
it has  been called, which the Arabians seem  to have considered  as
having some affinity  with the proper elephantiasis (juzam,)  but yet
is materially different in its symptoms ;  and which they have denomi-
nated baras, or barras, and albaras, and which appears to accord ac-
curately with the leuce of the Greeks, and  the vitiligo (species 3.)
of Celsus.—If the Hebrews did Sot  apply  the term  (translated)
leprosy, to several  affections of the skin) such as the  scaly  lepra
graecorum, the psoriatis of Dr. Willan, and the leuce, which I suspect
they did:) this leuce or baras would seem to be the unclean leprosy
described in Leviticus, Cap.  xm **
   " if your knowledge of the oriental languages will  enable you,
together with your knowledge of these diseases, to  disperse  some
  * See Avincen. Quart, in. or Lib. in. Fen. in. Tract, m. Cap. i.
  t Theorice Lib. vm. Cap.  xv., and Practice Cap. iv.  In which passages the
translator has used the word Elephantia, and not Lepra,  like the other translators.
  X Theorice, Lib. vm. Cap.  xvm.
  i Lib. in. Fen. xxn. Tract, i. Cap. xvi or xvm.
  U Ad Almanzor. Lib. IX. Cap. xcm.
  IT Lib. n. Cap. xxvi.
  • *■ This is the opinion of two learned old Germans, Leon. Fuchs, in his Para-
doxa JVIedicina;, Lib. n. Cap.  xvi.; and Gregor. Horst. in his Epist. to Hopner,
inserted in his Obscrvatii nes Medicinales, Lib. vm. Obs. xvin.— And Seniier
seems to be of the same opinion, Piact. Med.  Lib. v. Part i. Cap. XL. 
568                     H.EMATJCA.           [CL. III.-OR. IT.

of the thick mist in which the  translators have enveloped them, I
should be exceedingly glad to partake of a little of your light.
  The substance of the author's reply to this letter, already given
in a note to the volume of Nosology, but  which ought not to  be
omitted on the present occasion, was as follows :         .  .  n
  The Greeks became first acquainted with the elephantiasis from
their casual  intercourse with  Egypt.   To  this quarter, Lucretius,
adopting the common opinion, ascribes its origin ;

             Est Elephas morbus, qui propter fluraina JVili,
             Gignitur iEgypto in media neque praeterea usquam.*

             High iip the Nile, mid Egypt's central plains,
             Springs the Black Leprosy, and there alone.

  Arabia, however, seems  rather to have  been the prolific source
of this terrible scourge than Egypt:  if  we may judge from what
seems highly probablemamely that this is the disease with which Job
was afflicted in Idumea, a part of  Arabia, as described in the sacred
poem that bears his name under the  appellation of fiJHS y^l " the
stroke of the  scourge," 'and which affords, without question,  the
most ancient record in the world, composed in a mixt language of Ara-
bic  and  Hebrew;  and if we add to this the still more powerful argu-
ment that the Arabic  name of the disease has extended itself all over
the  east, and is almost the only name by which it is known in Egvpt,
Persia, and India, in  all which regions the disorder is about equallv
common.  Yet the Arabic name is  not elephas or elephantiasis,  but
juzam, literally "disjunction,  amputation," vulgarly,  indeed,  and
more generally pronounced and  written judam from a root  which
imports  " erosion," " truncation," " excision;" evidently referring
to the destructive character of the disease, and  the  spontaneous
separation of the  smaller menibers, as the fingers and toes when
severe in its progress.
   The Arabians,  however, have  a  malady, but of a very different
 kind, to which they  also give  the name of elephas, or elephant affec-
 tion, in their own language dalfil, which is  literally morbus clephas:
 and which they sometimes contract tofil, or elephas alone.  It is the
 " swelled, tumid, or  Barbadoes leg," of modern writers, the bucne-
 mia tropica of the present system.  And, on this account, when learn-
 ing, and especially medical learning, found an asylum, during the
 dark ages, at the splendid courts of Bagdat, Bassorah, and Cordova;
 and the best Greek writers  were translated into Arabic, or the best
 Greek and Arabic into Latin,  two different  diseases  were  found to
 possess  a like name : for the Greeks,  notwithstanding that they had
 elephantiasis to signify juzam, could only translate dal fil by  elephan-
 tiasis also.   And  hence  arose that confusion of the  two  maladies
 which has continued to the present  moment,  notwithstanding  the
* De Rer. Nat. vj,
1112. 
©E. VII.]
SANGUINEOUS FUNCTION.
569
 wide distinction between them, the one being a tubercular affection
 of the whole body, while the other is a scaly affection of only par-
 ticular parts, and commonly of not more than a particular limb.
   The  leprosy properly so called,  the  leuce (xivxv) of the Greeks,
 and  the baras or beras of the Arabians, was, by  many of the Arabian
 physicians, and very generally among the people, supposed, in vari-
 ous  cases, to terminate in juzam or elephantiasis, as  though this
 also was nothing more than a different stage or degree of the same
 disease.   And hence another  error and perplexity in medical study.
 Alsahavarius thus unites them, and  they are  jumbled together or
 explained alike in nearly all  the oriental  dictionaries; in  which
 beras or leprosy, and juzam or elephant-skin, are, almost without an
 exception, regarded as  convertible terms.   This oriental confusion
 of two very different diseases was readily copied  by the Latin trans-
 lators, till at length, both in the  east and west,  beras  or lepriasis,
 though literally scale-skin, became a sort of family name for almost
 every foul disfigurement of the skin, whether tubercular, or scaly,
 cutaneous or constitutional.   And, on this account, elephanti-'sis  and
 leprosy,  and  several other diseases even in the  nosology of Linneus,
 are  included under the term lepra; all  which the disciples of this
 school, extending  a principle  very widely adopted by them, ascribe
 to animalcules  drunk in with the common beverage of water,  espe-
 cially the gordius marinus.
   The author  ought not to  conceal Dr. Bateman's acknowledgment
 of this communication, and his assent to its explanation contained in
 the  following opening of a letter received a few days afterwards :
   " I thank you sincerely for your ready and interesting communi-
 cation, which satisfactorily  explains  the point, respecting which  I
 was the  least able to obtain  satisfaction from the translators, viz.
 that the  Arabians had applied the term elephant  (elephas, according
 to the able  translator of Haly Abbas,)  or fil, as you  state  to  the
 swelled  leg.   This is some apology for the  appropriation of  the
 Greek term  elephantiasis, (though  it actually denoted a  different
 disease)  to the Arabian  thick leg ; but the  appropriation of lepra,
 which is never mentioned by the  Greeks  but  as a " superficial,
 rough, and scaly affection,"  to the tubercular juzam,  has unfortu-
 nately misled and  confused us for a thousand years "
  Dr. Bateman adds, that he apprehends the term elephantiasis had
 also a reference to the magnitude and duration  of the disease, inde-
 pendently of the appearance of the skin.   And it is very probable,
 as the malady was likewise sometimes  denominated leontiasis, that
 the formidable and frightful aspect of the patient labouring under it,
 may have been hereby  compared to  the  general exterior of both
 the elephant  and the lion: for  while Aretaeus tells us, in describing
it, that " it is disgusting to the sight, and in all respects terrible like
 the elephant,"  Avicenna, affirms,  " it renders the countenance ter-
 rible to look  at, and somewhat  of the form of the  lion's  visage."
  Besides the  elephantiasis of the Arabians, we  have  a disease of
 the same kind,  or  which seems to be of the same kind, common to
  vol.. n.                     72 
070                    HJLMATICA.           [CL, II1.-OR. Ff.

some parts of Italy, and another common to some parts of Spain;
both which seem,  indeed, to have issued from the Arabian stock.
And hence elephantiasis, as  a genus, offers  us the  three following
species :■

1.  ELEPHANTIASIS AKABICA.       ARABIAN ELEPHANTIASIS.
2.------------ITALICA.       ITALIAN ELEPHANTIASIS.
5.-------»- ASTURIENSIS.    ASTURIAN  ELEPHANTIASIS
                         SPECIES  I.

            ELEPHANTIASIS  ARABICA.

        Arabian Elqjfianttams.  Eiacft Hrjuosy.

TUBERCLES CHIEFLY ON  THE FACE AND JOINTS; FALL OF THE HAIR EX-
  CEPT FROM THE SCALP: VOICE HOARSE AND NASAL: CONTAGIOUS AND
  HEREDITARY.

This species, which is the oldest of the three, is also the most in-
veterate : for we do not know that the Italian  species is contagious,
though, like the Arabian, it appears to be hereditary: while the Spa-
nish is, perhaps, neither contagious nor hereditary.
  In some parts of the world, indeed, even the present species is
said not to be contagious,  though all the writers concur in its being
hereditary in every quarter. Thus Dr. Schilling, while he admits the
latter effect, asserts that it is not contagious in Surinam : and Dr. T.
Heberden asserts the same of this disease  in Madeira.  " I not on-
ly," says he, " am a daily witness of communication between lepers
and other people without the least ill  consequence, but know seve-
ral  instances where a  leprous husband (afflicted with the Arabian
leprosy  or elephantiasis)  married to  a  sound wife, has cohabited
with her for a long series of years, and had several children by her,
without her having contracted the least symptom  of  the disorder,
although the children  have inherited it; and vice versa, between a
leprous  wife and sound husband."*
  That the disease, however, is contagious as well as hereditary in
India and Arabia, we have the concurrent testimony of all the medi-
cal  writers of both countries, native as well as  foreign ; so that there
can be no  doubt upon the subject.  And  hence, the Madeira and
Surinam juzam  should seem to be a variety of the oriental, influen-
ced by peculiarity of climate or some  other incidental cause.
  This severe  malady, wherever it shows itself is sometimes slow
in its growth, and continues many years without deranging the  func-
* Medical Transactions, Vol. I. p. 35. 
GE. VII.-SP. I.]      SAN6UINE0US FUNCTION.               571

tions of the patient:  yet great deformity is advancing upon his ex-
ternal  make.  The alse of the nose become swelled and scabrous,
and the nostrils are preternaturally dilated; the lips are tumid; the
external ears, particularly the lobes, are  enlarged  and thickened,
and be6et with tubercles.  The skin of the forehead and cheeks
grows  dense and hard, and forms large and prominent rugae, espe-
cially over the eyes ; the  hair generally,  except on the head, falls
off;  the voiGe becomes hoarse and obscure; the external sensibili-
ty is obtuaded or totally abolished, so that pinching  or puncturing
gives no pain.  The tubercles at  length begin to crack, and ulce-
rate ; ulcerations appear in the throat  and nostrils; the breath is
intolerably offensive ; the palate destroyed; the nose  falls off; the
fingers and toes, from the increased depth  and  virulence of the ul-
cerations become gangrenous, and  separate, and drop off one after
another.   The mental powers suffer less than in the two other spe-
cies : the dreams, however, are greatly disturbed, the manners, for
the most part, morose and melancholy; and sometimes there is an
inextinguishable desire of sexual intercourse.
   This disease is also known  in the high northern latitudes of Nor-
way and Iceland.  In the last  place, it is peculiarly prevalent, pro-
duced, as Dr. Henderson justly observes,  by the rancidity  of the
food usually fed on,  wet woollen  cloths,  an insalubrious air, and
want of cleanliness.   It is called " Likthra," or " Putrefaction:" and
a hospital is established  for  it in each of the  four quarters of the
island.   It seems to be  here both  infectious and hereditary.  " In
its primary stage," says Dr. Henderson, " its symptoms are incon-
siderable.   A small reddish spot, scarcely larger than the point  of
a needle, breaks out at  first about  the forehead, nose,  corner of the
eyes and lips: and in proportion as it increases  other pustules make
their appearance on the breast, arms, arm-pits, which generally dry
up in one place and break out  in  another without pain, till the dis-
ease has considerably advanced, when they cover almost the whole
body, give the skin a scabrous  appearance, stiffen it  sometimes  in
shining scales which  fall  off like  dust,  sometimes in malignant tu-
mours  and swellings.  The patient, in the mean time, labours under
lassitude of body, anaesthesia and lowness of spirits."   The  misera-
ble progress is nearly a transcript of  the description just given.
The patient is so worn out with fatigue and melancholy, as to be of-
ten tempted to make  way with himself.  He surrenders one part of
the body  after another to the insatiable malady; " till at length,"
says Dr. Henderson,  " death,  the long-wished-for deliverer, comes
suddenly and puts an end to his misery."*
  The cure is extremely difficult; but a course of warm diaphore-
tics succeeded by tonics and especially the metallic tonics, seems to
have constituted the  most successful plan.  Hence  a free use  of
sarsaparilla, mezereon,  or guaiacum, has been found beneficial; and
  * Iceland, or the Journal  of a Residence in that Island, Vol. i. p. 295,  8yo„
Edin. 1818. 
572                    H.EMATICA.           [«- UI.-OR. IV-

mercurial  alteratives still  more  so;  though salivation appears to
have been uniform!v mischievous.  Even the lobelia has had it« ad-
vocates, and upon  the ground  of  its  proving salutary in  syphilis  it
has probably also been sometimes serviceable in elephantiasis.  Dr.
Schilling endeavours to increase  the  determination to the skin,  by
advising a use of the warm-bath and gentle exercise, and embrocat-
ing the bodv with  spirit of wine or rum or exposing it to a vapour-
bath of mastic, ohbanum, benzoin, or lavender.
   In India the  cabirajas, or native physicians, after bleeding and
purging, immediately apply to the  metallic tonics, and particularly
to the white oxyde of arsenic, which they give as in the case of sy-
philis, and indeed of various other impurities of  the  blood,  in the
form of pills;  mixing the  arsenic, which,  in  Hindustanee, is sane
hya, and in Arabic, shucc,  with six  times  its weight of black pep-
per into a mass with a little water; so  that each pill may contain
about two-thirds of a  grain of arsenic and four grains of pepper,
which is to be  taken twice a-day.  And this medicine is regarded
almost as a specific antidote.   It has no doubt proved often success-
ful :  and I have known various cases  in our own country in which
it has been found equally so in the form of the  arsenical solution.
   In this quarter  of the globe, however,  Mr.  Playfair has. of late
years revived the  use of one of the species of asclepias or swallow-
wort.  In Europe,  the  a. Vincetoxicum was formerly in high  favour
as an alterant and alexipharmic, and was often denominated contra-
yerva Germanorum: but its virtues were not sufficient to support
its character.   The swallow-wort employed by Mr. Playfair is the
a. gigantea, a native of the  east, and appears, from an account late-
ly published by Mr. Robinson,* to be possessed  of more  active and
possibly  more salutary, qualities.  It is the nudar  of Hindustan.
  The tonic found most useful by Dr. T. Heberden in Madeira was
bark, which however, has not proved of equal success in other pla-
ces or  the hands of other practitioners; but he employed it in con-
nexion with that course of external stimulants which has been found
generally serviceable, and  probably  not a little  contributed  to  its
wonderful efficacy  in the various cases he  refers  to, and particular-
ly one of a confirmed and chronic attack.  " I have,"  says he, " in
this island experienced the use of the bark in four or five leprous
patients  with success.    One had a confirmed elephantiasis; the oth-
ers were only incipient; having no other symptoms than  florid or
livid tubercles in the face and in the limbs.   The confirmed ele-
phantiasis was  attended with  livid  and scirrhous tubercles  which
had overspread the face and limbs ; the whole body was emaciated •
the eye-brows inflated ; the hair of the eye-brows fallen off entirely ';
the bones of the nose depressed ;  the  alae nasi tumefied, as likewise
the lobes of the ears; with a suffusion on both  eyes  which had  al-
most deprived the  patient of his sight.   There was a want of sensa-
* Medico-chirurg. Trans. Vol. 3^. 
GE. VII.-SP. I.]      SANGUINEOUS  FUNCTION.               573

tion  in  the extremities; and  a loss of motion in the  fingers and
toes."
  For upwards of seven years Dr. Heberden had used every medi-
cine  he could think of to relieve this patient, but in vain.  Antimo-
nials and mercurials of almost every kind; neutral salts, the warm
diaphoretics, as sassafras, and sarsaparilla, warm baths, and medicat-
ed baths, were alike  fruitless.   On May 2, 1758, he  made  his pa-
tient commence an electuary of powder of bark, with a third part
bark of sassafras root, inspissated with syrup.  And of this the quan-
tity of a large nutmeg was ordered  to be  taken  twice a-day.  The
patient at the same time had  his arms and legs bathed with an em-
brocation consisting  of an ounce of lixivium  of  tartar  and two
drachms of spirit of sal ammoniac, intermixed with  half a pint of
proof spirit.  By the latter end of May, the tubercles were conside-
rably softened :  by June 28, they were dispersed ;  a red scurfy ef-
florescence alone remaining behind, which in ten days lost its florid
hue, and peeled off, leaving the cuticle sound and clean. " The pa-
tient," says he,  "gradually recovered the sensation in his legs and
arms, and the use of his toes and fingers; the hair has grown again
on his eye-brows ; and the only remainder of the distemper which I
can perceive, is that the nose continues somewhat  flatter from the
depression of the bones.   The suffusion is quite cured, and the pa-
tient is ivaaexa  *xt tv%{oosf* of a healthy skin and colour.
                        SPECIES  II.

            ELEPHANTIASIS  ITALICA.

                  Ktaltau Elephantiasis.

TUBERCLES CHIEFLY  ON THE BODY AND  LIMBS, SOMETIMES  DESQUAMMAT-
  ING : GREAT TENSION OF THE  SKIN :  VERTIGO : BURNING, LANCINATING
  PAIN IN THE HEAD : MELANCHOLY, AT FIRST REMITTING, AFTERWARDS
  FIXT, TERMINATING IN ALIENATION OF MIND :  HEREDITARY.

For a knowledge of this species we are almost exclusively indebted
to the Italian physicians who have generally  given it  the  name of
pellagra or pelagra.  The first  writer upon the subject appears to
have  been Francis  Frapolli, a physician of Milan, whose work, " In
morbum vulgo Pelagram dictum," was published at Milan in  1771,
and who expresses himself doubtful whether the disease, though not
antecedently described, is not  referred to occasionally by earlier
writers, although he does not think that  the pilarella, as the syphi-
lis was called when it proved depilatory to the chin and eye-brows,
* Med. Trans, ut supra. 
574
HiEMATICA.
[CL. 1II.-0R. IV.
was the disease in question, notwithstanding this seems to have been
an extensive opinion at the time.  The next tract of any note upon
the subject, was published at Venice in 1784, by G. M. d'OIeggio,
under the title of « A Theoretical and Practical Treatise on the Dis-
eases of Vernal Inoculation, commonly called  Pellagra."*   But the
best account we have received of this complaint is from the pen of
Dr. Jansen of Leyden which appeared  in 1788, and  asserts that it
is endemic in the Milanese  territory.t  It is, in truth, common to
both the  Milanese and Venetian  territories as well as to other  dis-
tricts widely differing  in  soil and temperature: and can scarcely,
therefore, be referred to either of these sources.  It  is  commonly
ascribed, as we  have observed above, to the  heat of the sun's rays
after the chill of winter, and  is hence called mal del sole, which we
have just seen, was the view taken  of it by d'OIeggio;  while by
Odoardo it is attributed to a scrophulous  habit,! and  by  Videmari
and others, who have too much limited themselves to  the nature of
the eruption, to an impetiginous impurity.§  But none  of these ex-
planations seem to rest on any very solid foundation ; and, upon the
whole, we have more reason for regarding it, as produced by the
debilitating causes of hot, confined air, want of cleanliness and  bad
diet, operating in many cases upon a  diathesis hereditarily tainted.
It is found chiefly among the  Milanese and Venetian  peasantry,
whose  hovels are full of wretchedness, and rarely makes its appear-,
ance till  after the age of puberty.
  The first symptoms of the disease are general languor, listless-
ness, gloom, feebleness, and stupor in the legs, and  hence unsteady
walking; vertigo and confusion  of ideas.   Domeier, another writer
upon the subject, extends the stupor  of the legs to the entire frame,
and asserts that anaesthesia is a characteristic symptom of this species.|j
But this  assertion is not confirmed by the history of other patholo-
gists :  though the languor and inertness is often very great as well •
as universal.
   These symptoms usually take place in the spring;  and,  as the
summer  approaches, a sense of tension,  burning, and itching, is felt
in every external organ except the head, followed by an inflation of
the epidermis, and tubercles of, a shining red colour.   After some
days, the tubercles desquammate, and the skin appears at first red,
but soon recovers its natural  colour.  As the summer,  however,
advances,  every  symptom  commonly  subsides,  and the. strength
returns with the winter.  But if the symptoms do not thus subside.,
they become considerably exasperated and form a second stage of the
  * Tratto teoretico-practico delle malattie dell insolato di primavera volgari-
mente dette della Pellagra.
  t De Pelagra morho in Mediolanensi Ducatu endemio.
  X D'una spezia particolare di Scorbuto.  Venet. 1776.
  J Da quadam Impetiginis specie, morbo apud nos in rusticis nunc frequention
vulgo Pellagra nuncupata, 8vo. 1790.
  || Baldinger, Journ. xxvi. p. 9. 
1EE. VII.-SP. II.]       SANGUINEOUS  FUNCTION.            57.5

disease : in which the itching grows more pungent; the heat more
fiery;  the  skin  harder,  cracked,  and chapped; the  debility  is
greater ; the mental functions are disturbed generally ; the appetite
is  irregular; the sleep broken,  with acute  pain in the head and
spine,  soon followed  by  delirium.   The cutaneous affection now
diminishes; but the  nervous  symptoms are greatly augmented.
The vertigo increases; the  patient is sad and loves solitude, and
melancholy delirium alternates with  furious mania.  The taedium
vita? is insupportable,  and self-murder is a frequent consequence.
Strambio remarks that those who labour under this  disease have
the greatest tendency to drown themselves, " as by an hallucina-
tion," says  he, " opposite to  that of hydrophobia."*  Coercion is at
last  necessary;  and  a diarrhoea, atrophy,  or  dropsy  closes the
dreadful scene, if the patient do not sink earlier from corporeal
and mental exhaustion.
   The treatment need not essentially differ from that of the pre-
ceding species.  Pure air, habitual cleanliness,  warm bathing, and
a nutritious diet, with such tonics, whether vegetable or mineral, as
best agree  with the constitution, have proved most successful, where
the disease has not advanced beyond the  reach of recovery.
                       SPECIES  III.

         ELEPHANTIASIS  ASTURIENSI&

                ateturtan SSlejrttantfaste.

TUBERCLES CHIEFLY ON  THE  HANDS AND FEET ; CRUSTACEOUS, DESQUAM-
  MATING ; CONTINUAL TREMOR OF THE  HEAD AND UPPER PART  OF THE
  TRUNK ; BALDNESS OF  THE SCALP, AS WELL AS OF OTHER PARTS : GLOOM
  AND TERROR  OF MIND.

This species agrees in many of its symptoms with the Italic, and if
is  only  worth while  to notice the  points in which  they  differ.
Upon the whole, we may observe, that all the species coincide  is
being founded on an exhausted constitution, in the general character
of the tubercles  and in their fatal termination by dropsy, atrophy,
or some  other asthenic disease.  The Arabic species attacks the
face, the roots of the hair  and the palate-bones before the remain-
ing parts on which it preys are  diseased, and the affection  of the
skin increases  with  the increase  of  the  other symptoms.   In the
Italian species, the affection of the skin diminishes as the nervous
and mental commotion augments.   The pellagra also is distinguished
* De Pellagra, Observationes.  Ann. i. n. m. Mediol. 1735. 
576
HiEMATICA.
[CL. III.-OR. IV.
by thick urine, double vision, and a  peculiar mouldy smell of the
sweat.  In  the  Asturian  species, the  crustaceous tubercles  are
peculiarly painful; highly fetid, deeper furrowed with cracks,  and
more disgusting to the sight;  attacking the head as well as other
parts indiscriminately, and destroying the roots of  the hair.  The
mind is less  affected than in  the last,  and with melancholy  and
terror rather than with raving delirium.
  Tbis  species constitutes the Asturian leprosy of Thiery, Vander-
monde,  and Sauvages; but genuine  leprosy is not  a constitutional
complaint; and the present  is its proper place.  As the tubercles
desquammate, the skin appears  of a glossy leprous red,  and  the
disease is hence called by the Spaniards Mai de la Rosa.
  The  causes are extreme  poverty  and its attendants, filthy  bad
diet,  and  crowded unventilated  rooms  in  the deep and  swampy
vallies of the country, almost impervious to the rays of the sun:
and hence the medical treatment and general regimen recommended
under the  preceding species  will afford  the fairest promise of
success  here.




                   GENUS  VIII.

                      CATACAUSIS.

        " (Sfeueral (tombustiUlitn  ot the iio&g.

The peculiar  state of the constitution which lays  a foundation for
the present genus of morbid affections  is of a very singular  and
mysterious kind ;  and the only medical work that has referred to it
in our own country, antecedently to the  author's  own system of
tNosology, is Dr. Young's Medical Literature, in which it is noticed
under the Greek name here applied to it, derived from  xxtxxxm
" exuro."   One  only  species  has  hitherto been  discovered ae
belonging to it;  which,  from the peculiar habit  under which it
occurs, may be distinguished by the name of
1. CATACAUSIS EBRIOSA.
INEBRIATE CATACAUSIS. 
GE. VIII.-SP. ifj     SANGUINEOUS FUNCTION.
577
                          SPECIES  I.

                CATACAUSIS EBRIOSA.

                    Xnefcrfate  (Eatacausts.

 THE CONSTITUTION INFLAMMABLE IN CONSEQUENCE OF A LONG AND IMMODE-
    RATE USE OF SPIRITUOUS LIQUORS : THE COMBUSTION EASILY EXCITED OR
    SPONTANEOUS.

 In this wonderfuf^nalady, the art of medicine can be  rarely of any
 avail; since the mischief is, in  almost all instances, only  to be
 discovered after a cessation of life, and the destruction of some part
 of the body by an  actual flame, or  fire, in many instances sponta-
 neously issuing from its surface.  There may be some difficulty in
 giving credit  to so marvellous a  diathesis;  yet examples  of its
 existence and of its  leading to a migratory and fatal combustion are
 so numerous and so well  authenticated,  and  press upon us from so
 many different  countries and eras, that it would be absurd to with-
 hold our assent.  In almost every instance, the combustion seems to
 have  taken place in females,  advanced in life, and immoderately
 addicted to spirituous liquors.*  In some cases the heat that has set
 them on fire appears to have originated in themselves; in  others to
 have been communicated  by a stove, or a candle :  or a  stroke of
 lightning ;t but in no  case has the fire  or flame hereby excited in
 the body been  so powerful as essentially to injure the most combus-
 tible substances immediately adjoining it, as linen or woollen furni-
 ture.  The body, in several instances, has been  found  actually
 burning, sometimes with an open flame flickering over it; and some-
 times with a smothered heat or fire  without any open flame what-
 ever : while the application of water has occasionally seemed rather
 to quicken than impede the igneous progress.
   This is the more  extraordinary,  as  the human body,  in  every
 other state we are acquainted with, whether of health  or disease, is
 scarcely at all combustible of itself, and cannot be reduced to ashes
 without the assistance of a very large pile of faggots or other fuel,
 as universal experience in this very ancient mode of sepulture, and
 the  history of martyrs, who  have  been condemned to the flames,
 abundantly  testify.
  The event has usually taken place at  night when the sufferer has
 been alone ; and has commonly been discovered by the fetid, pene-
 trating scent of sooty films which  have  spread  to a  considerable
distance; the unhappy subject has, in every  instance, been found
dead, and more or less  completely burnt up;  the  burnt  parts
            * Bartholin, Act. Hafn. I. Obs. 118,
            t Fouquet, Journ. de Med. Tom. Lxvnr
VOfc.  M.                   73 
578
H/KMATICA.          [CL. III.-OR. IV.
being reduced to an oily, crumbly,  sooty, and  extremely offensive
matter.  " I  confess," says  M.  Pierre-Aime-Lair,* that these ac-
counts  at first appeared to me to be  worthy of very little credit, but
they are presented  to the public as  true by men whose veracity is
unquestionable.  Bianchini, Maffei,  Rolli, Le Cat, Vicq d'Azyr, and
other men distinguished  by their  learning, have  offered certain
testimony of the facts.  Besides it is not more surprising to meet
with such incineration than a discharge of saccharine  urine, or an
appearance of the bones softened to  a state of jelly."
  Those who are desirous of pursuing this curious  subject farther,
and of entertaining themselves with  the very extraordinary histories
connected with it, as also of examining  the various hypotheses by
which  they have been accounted for, may consult the Philosophical
Transactions, Vols,  xliii and xliv, the first of which contains numer-
ous examples;  as also a variety of foreign journals of established
reputation, referred to, and cited in the running commentary to the
author's volume of Nosology.   We have not  space to enter  into
these separate cases,  though many  of them are highly interesting;
but in  a general course of medical study, the phenomenon ought
not to be passed by : it forms one of  the most curious links in the
long chain of morbid affections, and equally demands our attention
as pathologists and  physiologists.
                     GENUS  IX.

                       PORPHYRA.

                           Scurbg.

•LIVID  SPOTS ON  THE SKIN FROM  EXTRAVASATED BLOOD ;  LANOUOR  AN»
         LOSS  OF MUSCULAR STRENGTH ; PAINS IN THE LIMBS.

Porphyra is in Greek what purpura is in Latin, literally  " the pur-
ple or livid disease."   The  latter has been very generally made
use of; but the  former  is here  preferred on two  accounts.  First,
that of technological simplicity,—the names of the genera under the
present system  being  uniformly of Greek origin.  And secondly,
because the Latin purpura has been  used in senses so numerous, so
vague, and  unconnected, that at this moment it conveys no definite
idea whatever.  ." The  term purpura," observes Dr. Bateman, most
correctly, " has  been employed  by different writers in so many ac-
ceptations that some  ambiguity would perhaps have  been avoided
by discarding it  altogether; for some authors have used it as an ap-
pellation for measles, others  for scarlet-fever, for miliaria, strophu-
* Journ. de Physique. Ann. vm. 
GE. IX.]               SANGUINEOUS  FUNCTION.            479

lus,  lichen, nettle-rash, and  the  petecchiae  of  malignant fevers;
while formerly it was applied to petecchial spots only by Riverius,
Diemerbroeck, Sauvages, Casson, and some others."*
   The usual synonym for purpura is scorbutus; but to this there are
still  stronger  objections.  For as  a term  it is neither  Greek  nor
Latin,  nor any language whatever; but an  intolerable  barbarism,
derived, as is commonly supposed, from  the  German compound
schar-bocke  literally  " aggregate-pox,"  " cluster-pox;" but  more
likely  from  scharf-pocke, " violent, or vehement pox ;" or schorf-
pocke, " scurf, or scurvy-pox," to which the inventor has  endeavour-
ed to give a sort of Latin  termination.   Independently of which
scorbutus, as employed at present,  only indicates a particular species
of scurvy ; and could not therefore, without imprecision, be used in
a generic signification.
   The sense here expressed  by porphyra, runs,  as  nearly as possi-
ble,  parallel  with the  range assigned by Dr. Willan to  purpura.
" With Riverius and some other  authors," says  he, " I propose to
express by the term purpura an efflorescence consisting of some dis-
tinct, purple specks and patches, attended with general debility, but
not always with fever."  And again " cases of the purpura seem to
have been studiously  multiplied  in periodical publications, and in
medical or  surgical miscellanies.   I consider it under all the forms
described as pertaining to the scurvy, though it is  not always attended
with sponginess of the  gums, and a discharge of blood  from them
according to the definition of scorbutus in nosology."t
   Porphyra, in its present signification, is intended to include every
description of petecchial eruption, and spontaneous  ecchymosis not
dependent on fever as their  cause, in which case these affections
are  only symptomatic.
   The genus  thus  explained will associate  under its banners  the
three following species:
                                            PETECCHIAL-SCURVY.
                                            LAND-SCURVY.
                                            SEA-SCURVY.
* Synops. of Diseases, p. 102.
t On Cutaneous Diseases, Ord. in. p. 453.
1.  PORPHYRA SIMPLEX.
2.--------HEMORRHAGICA.
3.  -------- NAUTICA. 
580
HiEMATICA.
[CL. II1.-OR. IV.
                          SPECIES I.

                PORPHYRA  SIMPLEX.

                     $eteccfual Snirfcs.

 SPOTS NUMEROUS, BUT  SMALL AND FLEA-BITE-SHAPED ;  CHIEFLY IN THE
           BREAST, ARMS AND LEGS;  PALENESS OF VISAGE.

 Pulicose or petecchial spots were at one time supposed  to be, in
 every instance, the result of debilitating and putrid fever*.   Riverius
 is, perhaps, the earliest author who distinguishes between simple
 petecchiae, and petecchial  fevers.  Vascular debility or relaxation
 is, however, the predisposing cause in both cases.   They neces-
 sarily, indeed,  accompany each other, and,  wherever they exist in
 any considerable degree, they lay a foundation for those minute ex-
 travasations which constitute the  present species; and which may
 take place either from occasional ruptures of the weakened coats
 of the minute subcutaneous blood-vessels, in consequence  of their
 being incapable of resisting the  impetus  of the  blood  that flows
 through them; or from the mouths of many of them, which should
 give forth only the finer and limpid particles of the blood, yielding
 and allowing  an exit to the  red globules.
  Both these may follow upon atonic fevers; but the usual remote
 causes in the species before us, are severe  labour with innutritious
 or spare diet, and especially with impure air; an impoverished state
 of the system from a sudden and profuse loss of blood; a sedentary and
 inactive life or some chronic and  exhausting disease  by which the
general strength has been  broken down.  To these Riverius adds
suppression of the catamenia, and a certain mild ebulliency of the
blood in boyhood—levem quamdam sanguinis ebullitionem; a phrase
apparently importing an excess of sanguineous temperament: from
both which he tells us  he has frequently seen the disorder originate.
And he is confirmed in the  last by a case hinted at by Dr. Perceval
in his manuscript comment on the author's Nosology, in which  he
 observes  under the present  species, that  " in a young lady of a full
 habit, and florid complexion, if  the skin of the face or neck were
 touched even slightly  blood oozed from the pores."
  The disease seems also to be produced at times by some unknown
 cause; of which Cullen has given a striking instance in his Materia
 Medica.  " The patient," says he, " was a woman who had lived
 very constantly upon vegetable aliment and had not been exposed,
 so far as  could  be judged, to any febrile or putrid contagion; and
yet, without  any feeling of any other disorder,  was affected with
numerous petecchiae over  the whole surface of her body.  After
these had continued for some days without  any symptoms of fever,
she was affected with  swelled and bleeding gums, with fetid breath 
GE. IX.-SP. I.]       SANGUINEOUS  FUNCTION.    .         581

and much thirst;  and in the course of a week or two  more almost
every symptom of a putrid fever came on, and in a few days proved
fatal."
  It is possible in this case that the brain may have lost its energy,
and the blood  become impoverished  by too low a diet,  though the
history is not  given with  sufficient fulness to  speak with much de-
cision upon  this point.   The  fever was  evidently produced by the
irritability of  weakness,  and  necessarily ran into  a typhous  type
from the same cause.
  The disease, as it commonly shows itself, under two forms, which
may thus be described as varieties.

x Pulicosa.                         Exhibiting from  the first a
  Simple Pulicose Scurvy.              pulicose,  or flea-bite ap-
                                      pearance.
3 Urticaria.                        The  flea-bite spots preceded
  Nettle-wheal Scurvy.                by reddish, rounded and net-
                                      tle-sting  wheals, but  with-
                                      out the nettle-sting itching;
                                      fugacious and migratory.

  The first variety is not only produced  by debility, but  attended
with languor and pains in the limbs,  and chiefly affects women and
children  in consequence of their greater laxity of fibre.
  The second variety may possibly be accompanied with some kind
of acrimony in the blood,  and  something  more of a constitutional
affection; for  there is usually a loss of appetite, and an edematous
swelling  of  the hands and ankles;  while the  spots are brighter at
night and darker in the day;  evidently proving great irritability in
the capillaries, and  especially towards the  period of the natural
evening  paroxysm of fever,  and great atony in  the  absorbents.
This variety often continues for five or six weeks.
  Better  diet, freedom from hard labour, pure air, sea-bathing, the
mineral  acids, and other tonic medicines, afford a pretty certain
process of cure.
                        SPECIES  II.

         PORPHYRA   HEMORRHAGICA.

                       2Latttr=<Scutf}g.

SPOTS  CIRCULAR, OF DIFFERENT SIZES ; OFTEN  IN  STRIPES OR  PATCHES
  IRREGULARLY SCATTERED OVER  THE THIGHS, ARMS AND  TRUNK ;  OC-
  CASIONAL  HEMORRHAGE  FROM  THE MOUTH,  NOSTRILS  OR  VISCERA :
  GREAT DEBILITY AND  DEPRESSION OF SPIRITS.
This species is sometimes marked by febrile  paroxysms, with va- 
582
PLEMATICA.
[CL. I1I.-OR. IV.
 riable intervals, but usually occurring in the evening.   It has no re-
 gular or stated  termination.   Dr.  Willan has  found it  run on in dif-
 ferent cases, from fourteen days to a twelvemonth, and upwards.  It
 is met with at every period of life, but chiefly affects persons  of a
 weak and delicate habit;  often children, principally women.
   The precursive  symptoms are lassitude,  faintness, and  pains  in
 the  limbs, so  that business or even  company,  is found fatiguing.
 After this there are often shiverings, nausea and vomiting   The
 purple eruption appears first  on the legs, and afterwards, at irregu-
 lar periods, on  the thighs, arms, and trunk  of the body;  the hands
 and face generally remaining free.  The spots,  however,  are  fre-
 quent on  the interior  of  the  mouth, and  particularly the tonsils,
 gums and lips :  where  they are sometimes raised or papulated.  It
is here the first hemorrhage  commonly issues, though, as  the  dis-
ease advances, blood flows also from the nostrils, lungs, stomach, in-
 testines, and uterus.  The hemorrhage is  often profuse  and cannot
 easily  be  restrained, and is accompanied with pnasarcous swellings.
It sometimes precedes  the purple spots, but  more commonly takes
place a few days afterwards.
  The most usual remote  causes of the present, as of the preceding
species, are poor diet,  impure air, anxiety of mind, and a sedentary
mode of life : and if women under these circumstances, and affected
with this complaint, are wet nurses, their infants participate  in the
disease from the milk not being sufficiently  nutritious.   It  is also  pro-
duced by habitual gluttony, and particularly by an habitual and im-
moderate  use of spirits; which have the  strongest tendency to  ren-
der torpid  the  collatitious organs of  digestion,  and especially the
liver;  whence  congestions and   other obstructions,  and  whence,
too, the larger  and  more dangerous hemorrhages that occur in  this
species.
  As  these causes  are widely different  in  their mode of  action
though  they concur in producing the same  effects, the treatment
must vary in like manner.
  Where  the source of the disease is poverty with   its miserable
train of attendants, poor diet, impure air, hard labour, grief of mind,
the mode  of cure recommended for the preceding species will be
found equally serviceable  here : but the  tonic power may be  car-
ried to a higher range ; the bark  should be freely administered, and
wine be liberally allowed.  The worst symptom is the tendency to
hemorrhage, which is sometimes  profuse  and restrained with great
 difficulty,  and has been known to  prove fatal.  Occasionally, how-
ever, an accidental hemorrhage has had a contrary effect,  and  car-
ried the complaint away ;  and hence Dr. Parry of Bath, has found
venesection serviceable.   Yet in these cases,  we may reasonably
suspect the second cause we have noticed,  namely,  some visceral
congestion, and especially that of  the liver, to lie at the foundation ;
and dissections  have proved  this to be no  uncommon cause of the
disorder.   The  symptoms of visceral obstruction indeed, are often
 Sufliciently clear; and where  these occur, antecedently to the tonic 
GE. 1X.-SP. II.]       SANGUINEOUS FUNCTION.              583

plan, we must freely and repeatedly evacuate the bowels; and may
advantageously have recourse to the lancet.
  In some cases of great laxity of fibre, the extremities of the larger
capillary arteries seem to sympathize with the state of the liver or
other visceral organs, and to relieve the oppression by a metastasis.
Willan has related a singular case of this disease which it is diflicult
to account for otherwise.  A lady aged  thirty-six, of the  sanguine
temperament, after experiencing, for several days  a painful infla-
tion of the stomach,  was seized on the 17th of June, 1792,  with vio-
lent vomiting, which continued almost incessantly through the 18th
and 19th, and was accompanied with excruciating pains in the bow-
els.  The fluid discharged was clear, strongly tinged with green bile,
and amounted to three or four quarts a-day.   The vomiting abated
about the 20th, and  she had loose stools of a green colour intermix-
ed  with black, coagulated blood.  This kind  of discharge  continued
till the  25th, producing great languor and faintness, thirst and rest-
lessness, with a cool skin and remarkably slow pulse.   On the even-
ing of the  25th, her extremities  became  suddenly cold,  the pulse
scarcely discernible, a cold sweat  trickled from every part  of the
body, her voice was indistinct, and her breathing laborious.  From
this alarming state she recovered in the course of the night; and on
the following day  a  rash appeared  over the  whole  body in small
and circular patches, confluent on  the  neck, shoulders,  and nates,
but in other places  distinct.   The  eruption diminished in two or
three days, and assumed a livid colour; and  the discharge of blood
ceased  from  this  time.  She  improved generally,  but  for  two
months suffered greatly from languor and debility :  the extremities
were, for a long time,  anasarcous, and two of the spots became gan-
grenous.
   The  account and causes now given of this species are such as we
usually  meet with  in the present day.  But if we look back into the
history  of this disease as far as the seventeenth century,  and espe-
cially to the state  of this metropolis, we shall  find hemorrhagic or
land-scurvy making a much  nearer  approach to sea-scurvy than in
our own time; not only in its symptoms, but  from the peculiar cau-
ses that seem to have given rise to it, and which are now,  for the
most part, removed.  The population within the walls of the old
city, was, at that period, far greater than at present, since the streets
have  been  very extensively widened, and  many of  them entireh
pulled down; and  fashion, which  does not always operate  so useful-
ly,  has led all who are capable of following its steps, into the more
salubrious air of the neighbouring villages.   Independently of this.
the supply of fresh vegetable  food for man, and of winter fodder for
cattle, was, at the period before us, so scanty, as to render it neces-
sary to salt a great quantity of the cattle that was killed in the sum-
mer season for winter's use.   To  which we have to add a far greater
degree of dampness and uncleanness, not  only in  the public streets
but also in private  houses.
  AH these are  also causes of sea-scurvy;  and  we  find  from the 
584
H^MATICA*
[CL. III.-OR. IV.
 description of Willis and others, that they produced conjointly very
 similar effects;  and that the  mortality hence  ensuing was very  m
 great.   The monthly deaths, according to the bills of mortality, oc-
 casioned by what is there called scurvy, were seldom  less than fifty,
 and frequently as high as ninety.  In the period of the plague, they
 are only set down at a hundred and five from this last cause for the
 year.  It was not, indeed, till the beginning of the sixteenth centu-
 ry that any great progress was made in the  art of kitchen-gardening
 in our  own country.   At this last period so low was the knowledge
 of this  art, that Queen Catharine of Arragon could not procure a sal-
 ad till a gardener was sent for from the Netherlands to raise it: nor
 were the most common articles of the  kitchen-garden, such as cab-
 bages,  cultivated till this reign.* And  such  was the  prejudice at
 one time entertained against pit-coal, from its being supposed to load
 the atmosphere with unhealthy fumes, but which is now become one
 of our most powerful ventilators, and consequently one of  our most
 active agents in promoting the general health of the city, that a law
 was formerly in existence which made it a capital offence to burn it
 within  the city walls; so that it was oilly allowed to be used in the
 forges of the environs.   Sir Gilbert Blane informs us  that  the late
 Mr. Astle, keeper of the records in the Tower, told him that he had
 there discovered a document importing that under the operation of
 this law a person had been  tried, convicted, and  executed  for this
 offence  in the reign  of Edward the first.—We learn also from Dave-
 nantt that heaps of the most noisome filth were suffered to accumu-
 late in consequence of the imperfection of  the  public sewers;  and
 that particular places were marked out  and assigned for such accu-
 mulations, which were called lay-stalls ;  and hence the name of Lay-
 stall-street, which exists in one or two parts of the metropolis even
 in the present day.
   The  same  happy causes, therefore, which have delivered us so
 generally from dysentery, remittent  fevers,  and  even the plague it-
 self, have freed us also from land-scurvy.  And it has operated over
 all the other large cities of England  as well as  over  the  metropo-
 lis : and over,the open country as  well as over the towns.  Even
 the remote districts of Somersetshire, not more  than a century ago,
 formed  a striking theatre for  the  exhibition  of this tremendous
scourge, as we learn from Dr. Musgrave's work,J  published in  the
year  1703.  " Agri Somersetensis, uliginosi  magna parte et depres-
<i, aerem crassum et  humidum trahentes, incolae,  maculis subnigris,
 ulceribus malignis, crurum dolore, respiratione difficili, lassitudine
spontanea, nervorum debilitate,  hydrope, gangraena,  et istiusmodi
aliis scorbuti exquisiti signis creberrime divexantur."
   The  picture is strongly and fearfully sketched, and precisely
  * Anderson's History of Commerce.—Sir G. Blane's article, Med.-Chir. Trans.
iv. p. 96.
  t Page 351. ed. 1673.
  X De Arthritide Symptomatic^. 
GE. IX.-SP. II-]      SANGUINEOUS  FUNCTION.              OOO

corresponds with the definition just offered.  How then comes  the
country, as well as the town, to be so  wonderfully and beneficially
changed in our own  day ?  " The same spirit of improvement" says
an admirable  writer,* from whom  1 have often  had occasion to
quote, and whose  words I would always give  rather than my own,
« which has  constructed our sewers, and widened our streets,  and
removed the  nuisances with which they  abounded, and dispersed
the inhabitants over a larger surface, and taught them to love airy
apartments, and frequent changes of linen ; has  spread itself like-
wise into the  country ; where it has  drained the marshes, cultivated
the wastes, enclosed the  commons,  enlarged  the  farm-houses,  and
established cottages.   Few, perhaps,  even  among physicians,  are
aware of the  extensive influence of these measures.   Few have ad-
verted with the attention it deserves to the prodigious mortality oc-
casioned formerly by annual returns of epidemical fevers, of bowel
complaints, and other consequences of poor and sordid living to
which we are now entire strangers."
   In  consequence of this  extraordinary improvement  in the best
branch of physical  philosophy, the  same attentive pathologist tells
us, that " For ten years, during which time he was one of the phy-
sicians to St. George's Hospital, the cases of genuine  scurvy  that
were brought into this establishment and fell under his care did not
 amount to more than four;—not one of which was severe.  In St.
 Bartholomew's Hospital, however,  about the year 1795, owing to
 the very great severity of the  preceding winter, various poor pa-
 tients were  received with  all the characters of true  porphyry ;
 which, in one man, were carried to such a height that he died in a
 most offensive state the day after he was admitted."
                        SPECIES III.

               PORPHYRA  NAUTICA.



SPOTS  OF DIFFERENT HUES INTERMIXED WITH LIVID, PRINCIPALLY AT THE
  ROOTS  OF  THE HAIR ;  TEETH LOOSE ;  GUMS  SPONGY  AND  BLEEDING J
  BREATH FETID; DEBILITY UNIVERSAL AND EXTREME.

This species is denominated sea-scurvy, not from its being exclusive-
ly limited to mariners and extensive fleets, but from its being most
common  to  persons thus occupied, and raging in  such situations
with the most fatal havoc.   For the peculiar, as well as the general,
causes which produce it at sea may also operate on shore, and have
        * Dr. Heberden, Med. Trans. Vol. iv. Art. vii.
VOL.  H.    v          74 
586
ILEMATICA.         [CL. III.-OR. IV.
at times operated with merciless ravage in besieged garrisons, and
among armies reduced to short provisions, or of unwholesome kinds,
;md worn down by fatigue, anxiety, and  exposure to a damp atmos-
phere.  Such seems to have been the condition of the Roman army
under the command of Germanicus, as related by Pliny ;  whose  ac-
count of the disease that preyed upon it, though vague and unsatis-
factory, coincides with the general appearance of sea-scurvy.  We
have similar descriptions in  several of the expeditions that took
part in the Holy Wars, and particularly that of St. Lewis as related
by Joinville.   We may hence conclude  that sea-scurvy is not a dis-
ease of recent times alone ;* though  it does not appear  to have at-
tracted any very general attention till the melancholy  result of the
famous voyage of Vasco de Gama in 1497.   The spirit of maritime
discovery was as this time in  full_ vigour and activity:  the Portu-
gueze, the Spaniards, the Dutch and  the English vied  with each
other in their efforts to explore remote and unknown countries;
the means of providing suitably for voyages of so great length were
little known ;  and hence the disease frequently made its appearance
during the  progress of the  next half century  and  raged with tre-
mendous violence.   It is well known,  indeed, that so  late  as  1741
the fleet under Captain, afterwards Lord Anson, lost half its crew in
the space of six months from the time it left England.
   The diagnostics and progress of the disease are neatly and accu-
rately concentrated by Dr. Parr,   its  first appearance is  evinced by
a pale, bloated complexion, lassitude, and a disinclination to motion,
with diminished energy, in the muscular fibres.  If the gums, even
in this early  stage,  be  examined, they will  be  found spongy and
apt to bleed on being touched ;  while the teeth are loosened in their
sockets.  The skin is sometimes rough, but more generally smooth
and shining, covered with blueish or livid spots, which  do not rise
above it; and these spots often coalesce in large  blotches, particu-
larlj' in the legs and thighs.  About  the same  period,  old  ulcers
often break out again, and the slightest mercurial preparation quick-
ly produces salivation.  The ulcers  discharge often a fetid sanies,
or are covered with a coagulated crust which is renewed whenever
it is separated.  The edges  are  livid with  irregular  granulations,
which sometimes run into a  bloody fungus.  During  the whole of
this period, the appetite continues good and, though  tensive pains
arise, and are  necessarily distressing, yet, on the whole, the patient
feels little inconvenience.
   The state  of the bowels is very various.  The stools are often
frequent and offensive, but there is sometimes  an obstinate costive-
ness.   The urine is commonly high-coloured and fetid;  the pulse
feeble, but rarely quick.  A  weakness in the joints appears early and
increases with the  disease ; and a shrinking of the flexor muscles
renders the limbs useless; producing the scorbutic paralysis of Dr.
Lind.   The calves of the legs fall away, with sometimes  an irregu-
* Compare Richter, Pr. Disquisitio in Hippocraticas Scorbuti antiquitates, &c. 
GE.  IX.-SP. III.]      SANGUINEOUS FUNCTION.             OoJ

iar hardness, and at length become  edematous: while  the  bones
themselves, no  longer  supplied  with a sufficiency of  calcareous
earth, give way at the callus of fractures ; and  those  which  have
been formerly broken and  re-united, become again  separate at the
line of reunion.*
   The last stage is truly distressing.  Blood is frequently discharged
from the intestines, bladder, and other organs.   The slightest mo-
tion brings on faintness, and often immediate death.  Catchings  ot
the breath and syncope, slightly and occasionally, indeed, found ear-
lier, are now .frequent, and dangerous; yet the sense of weakness is
so much less than its real amount, that  the  patient  often attempts
exertion, and dies in the very effort: though, more  frequently, he
survives the attempt for a  short time, and especially when animated
by any powerful and pleasant  motive, as the hope of getting on
shore, or even of engaging in fight with an enemy.
   The most obvious of the remote causes of sea-scurvy  is salt pro-
visions ; and perhaps the most obvious of its proximate causes is a
putrescent state of  the blood :  and hence these  are the causes  that
have been commonly assigned from the time of Sir John Pringle to the
present day.   Dr. Cullen was  so convinced  of the active power of
these two causes that he could hardly admit of the operation of any
other.  He supposes that the animal economy has a singular power
of producing and evolving a saline matter from  foods of every kind
which does not naturally exist in them, but more especially from a
diet that is wholly vegetable or wholly animal, though more so  in
the latter case than in  the former.   And he supposes,  next,  that
such saline matter is of an ammonial kind ;  and  that  whenever it is
produced or  evolved  in too large a  proportion,  it has a tendency,
like neutral salts applied to the blood when drawn from  the  body,
to dissolve  the crasis of the animal fluids, and render them putres-
cent, though, in a living state,  they hardly ever  proceed to an ac-
tually putrid stage.  And applying these general remarks to the dis-
ease before us, he supposes that " the throwing into the body along
with the aliment an unusual quantity of salt," which, by the action
of the body, he further conceives to be changed  into ammonia, must
have a great share  in 'producing that preternaturally saline,  and
consequently dissolved, or putrescent state of the blood  which con-
stitutes, in his view, the proximate cause of scurvy.]
   In other places, indeed, Dr.  Cullen supposes not merely that the
introduction of an unusual quantity of salt into the blood  may have
a great share in producing sea-scurvy, but that it  is probably its only
cause.  " Whether," says  he,  it ever arise in  any other circum-
stances is extremely doubtful; for  there is  hardly any instance of
the disease disappearing unless where salt meats had been employ-
* Aitken, Essays on several important subjects in Surgery, &c,
t Pract. of Phyt. '} mdcccxii, mdcccxiii. 
588
MJEMAT1CA.        [CL. IH.-OR. IV.
ed, and scarcely an example where the long continued use of these
did not produce it."*
  The great stumbling block to this hypothesis is, that while the
mineral acids, the  most powerful antiseptics we are acquainted with,
are of little or no avail, the plants most successful in curing the dis-
ease are those which are  most  alkalescent,  and make  the nearest
approach to an  ammoniacal property, as the alliaceous and telrady-
namiae.
  This view is, therefore, too limited in every respect.  That an
excess of salt, and particularly of salted meat, is a  powerful cause
in the production of scurvy,  is unquestionable; yet not more per-
haps from its tendency to  dissolve the fluids, for  the blood retains a
buffy  crust even to the last, than from its rendering the  salted meat
less nutritious.   But it is by  no means the only cause.  In the pre-
ceding varieties, we have  already seen it  produced on land  as well
as at sea,  and  in  some cases where  there was no  employment of
salt provisions.   And even sea-scurvy itself has occasionally been
found to arise where the diet has by no means been saline;  and in
damp situations, whatever has been the diet, unless where peculiar-
ly generous and stimulating: and  we have one instance of its hav-
ing occurred in a young woman who had subsisted almost wholly on
tea.
  In like manner,  though  the fluids of the body are  loose and  in-
coagulable, the muscular fibres are equally loose and  incontractile;
so that the latter,  as justly observed by that excellent  practical wri-
ter Dr. James Lind,t arenas much  affected as the  former:  and, if
we attend to  the course of the symptoms as they arise, we shall find
that they are affected soonest; for the earliest signs of  the  disease
are those of languor, debility, and  dejection;  though,  upon  the
whole, the mental depression is less  considerable than in land-scur-
vy ;  and, as we have already observed,  there  is a  sense of mental
energy to the last  which  is far more than commensurate with  the
actual strength  of the body.
  How far  salt provisions  alone might  produce  sea-scurvy it is
scarcely worth  while to inquire;  for there is  no extensive history
of the disease in which they have acted solitarily ; having always
been  more or less  united  with  a  cold or damp  atmosphere, great
fatigue, or a  want  of proper and invigorating exercise, want of ven
tilation, neglect of cleanliness, and very generally short rations, or
an unwholesome diet of other aliments  besides salt meat.
  Now these are causes which must have a direct influence on the
fibrous structure, and consequently on the whole organization of the
body  before the fluids can become affected; and it is  easy to trace
the changes which occur  in them subsequently to,  and through  the
medium of this influence.
   Under the circumstances we are now  contemplating,  the  diges
* Prac. of Phys. frj mdccxcii, mdcccxiii.
t Treatise on the Scurvy, Sic. p. 277. 
GE. IX.-SP. III.]      SANGUINEOUS FUNCTION.
589
tive organs suffer first;  they become weakened in their power, and,
for the reasons already stated when treating of marasmus, the weak-
ness will extend through the whole  range of the digestive chain,
and influence all the organs  of assimilation ; whilst  the lungs,  the
brain, the heart, and the skin, unite in the general debility.   Hence
none of the secretions will be sufficiently elaborated, or, perhaps, in
sufficient quantity :  there will be, a less supply of sensorial  energy,
and a less vigorous  action of the vascular system: a smaller forma-
tion of gluten, and  elimination of carbone  from the  lungs.  And
hence, as a necessary consequence, the  looser texture, and deeper
hue of the blood: for as the secretion of gluten becomes diminish-
ed, whose quantity is dependent upon the firmness  and elasticity of
the living fibre, the blood must evidently be  attenuated; and, as a
smaller portion of carbon is discharged by the lungs, the blood must
be proportionally of a darker colour.
   On this account Gintanner,* and other pathologists who refer sea-
scurvy exclusively  to a looseness of the solidum vivum, have more
to advance in their behalf than those who refer it exclusively to a
looseness of  the fluids.   But both are affected, and affected equally,
though the former takes the  lead.   Sea-scurvy is, therefore,  a dis-
ease whose proximate  cause is a putrescent, though not a putrid
state of the  animal solids and fluids produced  by an assemblage of
antecedents co-operating to a common effect.   In the course of their
 action, an acrimonious principle is unquestionably  evolved, which
 seems to exacerbate the  disease by increasing the  tendency to de-
 composition : and it is highly probable  that this acrimony is greatly
 augmented by the introduction of an excess of salt.
   It is assuredly, however, not necessarv that all the  causes we
 have adverted to should operate at the  same time.  But it  is of the
utmost importance,  both in preventing the appearance  cf the dis-
ease  and in affecting its cure where  it is present, to have  the eye
cautiously directed to every  one of them, and to destroy its agency
as far as we are able.  And it is owing to the  unremitting  attention
 which is paid to these points in the  navy of our own  country,  that
 sea-srurvy has  long been rarely heard of in English  fleets or Eng-
 lish merchant  ships; and that the globe is perpetually sailed over,
 and the highest as well as the  hottest latitudes  coasted and cruized
in, without the generation of this destructive plague.  And thus it
 has been ever  since the  celebrated  and extraordinory circumnavi-
 gation  of Capt. Cook in the Resolution ; in which, by first laying
 down a code of regulations for the government of his  crew, founded
on the soundest judgment, and afterwards persevering in them  with
 an unremitting  spirit directed to all the subjects before  us, he was
 enabled to fulfil his voyage of three  years and eighteen days with a
company of a hundred  and  eighteen men,  traversing all climates
from fifty-two degrees north to seventy-one south,  with  the  loss  of
only one man by disease ; and  that man apparently  labouring under
a consumption before he left home.
* In Blumenbach. Bibl. I'-md, in. p. 527. 
590
h^matica.
[CL. III.-OR. IV.
   The  regulations and management adopted by Capt. Cook,  are
contained in his  paper communicated  to  the  Royal  Society,  and
printed in its Transactions*  It is a paper of the  highest merit,  and
was justly honoured with the Copley medal for  the year.  In con-
junction with Sir John Prmgle's additional remarks upon  it,t  it has
laid the chief foundation for the present mode of treating this  dis-
ease, and particularly of providing against its attack.   The princi-
ples it unfolds should be canvassed  by the  nautical student in  the
communications  themselves, in conjunction with the later works of
Sir Gilbert BlaneJ and Dr. Trotter.§
   With the auxiliaries of cleanliness, proper ventilation, a dry at-
mosphere, and fresh provisions, the medical treatment  of sea-scurvy
is sufficiently simple, and the disease is found to yield  easity.  The
means more immediately effectual are all sorts of fermented liquors,
acid fruits,  the  alkalescent plants as garlic, scurvy-grass, water-
cress,  garden-cress, brook-lime, which, notwithstanding their alka-
lescence,  contain a great quantity of acescent matter, and by their
acrid property promote the excretions of urine  and  perspiration;
and the spruce fir, as well as other plants of the coniferous  tribe,
that contribute to the same purpose.
   The  fruit of the rubus  Chamemorus, or  cloud-berry, found on
boggy mountains in our own as well as  in more northern  countries,
is also a cheap,  and valuable  antiscorbutic.   In  Sweden, from  the
recommendation of Linneus principally, the berries are eaten very
largely as a confection;  the  Laplanders,  in  whose  gloomy region
the plant grows in great abundance, preserve considerable quantities
of the fruit in snow, and export them to Stockholm in casks.
  The  burdocks were formerly  very  much extolled in scorbutic,
and almost every other disease of the present order, and especially
the arctium Lappa, clotbur, or great burdock, common to  the wastes
of our own country,  which was supposed to possess all the powers
of the China and sarsaparilla roots.   The root given in decoction, is
certainly a diuretic, and diaphoretic; but as an antiscorbutic, it is of
far inferior merit to the plants already  mentioned.
   The infusion of malt as recommended by Dr. Macbride, does not
seem to have answered all the expectation  entertained concerning
it.  Dr. John Clark affirms freely and candidly that in  various cases
in which he tried it with all the concomitants of pure  air and good
nutriment, it had no influence  either in removing the  disease or in
checking its progress.   In consequence of which  he preferred Dr.
Silvester's  antiscorbutic drink, which is  made  by  boiling three
ounces  of cream of tartar,  four  ounces of juniper  berries,  two
drachms of ginger in powder, and five pounds of coarse sugar in six
  * Vol. lxvi. year 1776. p. 402.
  t A Disrourse upon some late Improvements of the Means for preserving the
Health of Mariners, Sic. 4to. Loudon.
  X Treatise on the Diseases of Seamen.
  ■$ Mclichiu Aautica. 
GE. IX.-SP. IH.]    SANGUINEOUS  FUNCTION.               0\fl

gallons of water.  After boiling half an hour,  the whole is poured
into a tub, and allowed to ferment.  It may be drunk as soon as the
fermentation commences, from one to three pints daily.*
  Capt. Cook, however, thought very highly of malt sweet-wort,
and esteemed it  one of the most powerful  antiscorbutics.   The
Russians, for want  of sweet-wort  or  table beer, employ a brisk
acidulous liquor,  called quas, formed by fermenting small  loaves
made of ground malt and rye-meal.  Dr. Mounsey tells us that this"
is the common  drink of both the fleets and armies of the Russian
empire.  Oatmeal is also occasionally used for the same purpose, in
the form of an acidulated gelatinous food denominated soins ; made
by infusing  the meal in water till a fermentation commences and
the liquor grows sourish, which, in a moderate  temperature, will
take place in about eight and forty hours.  The liquor is then poured
off from the grounds,  and boiled down to the  consistence of a jelly,
which sweetened with sugar, and mixed with a little wine, yields
an aliment not less palatable than medicinal.
   Pure fresh water is also another material  of great importance,
not only in curing this  disease but in guarding against it.  And of
so much moment did Capt. Cook  esteem its purity, as well  as its
freshness, that he had the old stock poured away, though procured
only a few days before, whenever he had an opportunity of obtaining
a  new  supply.  And at a time  when  it was  universally conceived
that the frozen water of the  ice-bergs consisted of salt water, or
was unwholesome as formed of frozen snow,  it was  matter of most
agreeable surprize to him to find that the  melted ice of the sea,
from whatever quarter derived, was not only sweet, but soft, and as
wholesome as the purest spring or river water;  thus affording him
a supply he  had no expectation of finding.
   The best  means  of preserving water  pure, is by keeping it in
casks charred for the purpose on their inner  surface : and the best
means for restoring it to purity when it has become foul and offen-
sive, is by mixing a little fresh powdered charcoal with every cask
before it is tapped,  and in drawing it off through a stone filtering
cistern, containing a bed of the same material.
   As fermented liquors  have been found serviceable, many of the
gases have been tried in their simple  form, and some of them  have
been thought serviceable ; but their  carriage, or the means of ob-
taining them extemporaneously, is  highly incommodious :  and it was
well observed by that excellent navigator La  Perouse, that seamen
may be gorged with bottles of them without  deriving a thousandth
part of the benefit produced from good slices of fresh meat, fruits,
and herbs.
   As the vessel of a tainted crew approaches  land, nothing is  more
common, or  apparently more  reasonable, than  for those that are
most affected to be most anxious to be put on shore at the moment.
Yet, for reasons we have already urged, this should rarely he com-
* Observations on the Diseases in lon^ Voyages, Sic. 3vo. 
592                   H^MATICA.            [CL. III.-OR. IV.

plied  with ;  for the real debility is so much greater than the appa-
rent, or, in other words, the energy of the mind is so much greater
than that of the body, that they often sink under the labour of the
removal, and sometimes die before they reach the asylum provided
for  them.  In cases of extreme  weakness,  the external air  alone,
and especially when sharp or in a current, is  sufficient from its
pressure and stimulus to puff out the  little  flame that  flickers in the
vital lamp ; a fact which, to adopt the words of Dr. Trotter, " has
been  long observed, and recently confirmed by five men dying in
the boat belonging to the Prince of Wales ship of war, between the
Downs and Deal hospital."
                     GENUS  X.


                        EXANGIA.

enlargement, breach, or  other morbid  perforation  of a large
            blood-vessel,  without external opening.

The expediency of placing this genus in its present situation among
diseases dependent on a " morbid state of the blood or blood-vessels"
would be obvious to every one even though the maladies  it embraces
were in every instance local.   This, however, is rarely the  fact;
for  the first two species  included under it result commonly from a
peculiar diathesis; and the last is productive of severe,  and  often
fatal constitutional, disorder.  These species are as follow :

         1. EXANGIA ANEURISMA.           ANEURISM.
        2. ------- VARIX.               VARIX.
        3. ------- CYANIA.              BLUE-SKIN.
                              SPECIES I.

                    EXANGIA  ANEURISMA.

                              Stneurfsm.

                     PULSATING TUMOUR OF AN ARTERY.

9    The disease of aneurism, which consists in a permanent dilatation
     or breach of the  coats of an artery, may be produced by external
     violence as a strain or puncture, or by arterial debility.   The last 
GE. X.-SP. I.]
SANGUINEOUS FUNCTION.
593
 is the more common cause, and it may be local or general:  it may
 be limited to the part in which the aneurismal swelling occurs,  or
 it may extend  through the whole range of the  arterial  system,
 which is sometimes  found to be universally, though  irregularly,
 feeble, and consequently feebler in some parts than in others.  It is
 this last  condition of the arteries which constitutes what has been
 called the  aneurismal diathesis :  and  under its  influence  aneu-
 rismal  tumours  not  unfrequently occur  in  different  arteries  of
 the same individual, simultaneously  or in succession*  De  Hnen
 gives a singular example of this in a boy  of seventeen :t and Lan-
 cisi has  conjectured  this diathesis to be produced by  gout, rheu-
 matism,  apoplexy, and a  sedentary  life ;| to which Guathani has
 added syphilis,§ and Freer, still more lately, inflammation of the
 arterial  tunics.   In all which cases we can trace the  common fact
 of great vascular debility  induced generally,  or in the particular
 limbs which have been the seat of the predisposing disease.  It is
 often accompanied with a calcareous  thickening and rigidity of the
 arterial trunk in particular parts.
   Aneurism is ordinarily represented as appearing under only two
 forms, the true, or as Mr. B. Bell more particularly denominates it, the
 encysted,|| and  the false or diffused.  To these it is necessary  to
 add the varicose of Dr. Hunter, and  the cardiogmus of the Greek
 writers ; thus presenting us with the four following varieties :
         x Cysticum.           Encysted aneurism.
         € Diffusum.            Diffuse aneurism.
         y Varicosum.          Varicose aneurism.
         J Cardiogmus.         Aneurism of the praecordia.
   The true or encysted variety forming the aneurism by dilatation
 of M. Petit,lT is  characterized by the tumour being circumscribed or
having a defined outline ;  and is  produced by a yielding or dilata-
tion of the coats of an artery so as to form a sac, which constitutes
the sphere of the arterial enlargement.
  The tumour,  when  first observed,  is  small  and  excites little
attention ; for there is no pain, the skin is of its natural appearance
and  the  tumour vanishes when pressed  upon by the  finger.  But
during the pressure a pulsation is clearly distinguishable  corres-
ponding  with that of the artery below.  As the disease advances,
the tumour increases; and when it has gained considerable magni-
tude, the skin  becomes pale,  and  even edematous;  the pulsation
still continues, but the tumour yields  less regularly to the pressure
of the finger than heretofore, being soft and fluctuating in some parts,

              * Saporta, Dissertatio de Tnmoribus.
              t  Rat. Med. iv. 2. i 7.
              X  De Subitanea morte, 100.
              i  De Aneurismatibus.
              ||  Sy-i. of Surg. Vol. I. Ch.  iv. p. 196.
              f  Metnoiies de l'Acad. des Sciences, 1736.
   •. o>. ii.           75 
594
H/K.MATICA.
[CL. III.—OR. IV.
but, from coagula lodged and hardened in the sac, firm and resisting
in others.   The  seat of the aneurism  at  length becomes distress-
ingly painful from the increased circulation and swelling; the skin
assumes a livid  hue,  and seems  verging  to a gangrenous state;
a bloody serum oozes from it, and it often ulcerates : when the walls
of the  arterial sac, meeting with  less  support than hitherto, give
way, the blood bursts forth with violence, and, if the artery be large,
soon produces death by inanition.
   Such is the general course of encysted aneurisms that show them-
selves externally;  but  as they often  occur in vessels more deeply
seated,  we cannot so readily mark their progress, and can often only
guess at their existence.  They have  been discovered,  however,
by particular symptoms in the chest, neck, head, forehead, temples,
and  back,  as  well as in every limb;  and it is difficult to say which
part is most subject to their appearance.
  In an early stage of the disease,  it cannot easily be mistaken for
any other; for the signs of a regular pulsation, absence of pain, and
disappearance of the tumour on pressure, are sufficient to distinguish
it.   But when, in the progress of  the complaint, the  pulsation
becomes almost imperceptible,  and the tumour hard, it  has been
confounded with other encysted tumours, scrophulous swellings, and
abscesses.  The  last is the most  common error, and, by leading to
an injudicious opening, has sometimes proved a fatal one.*
  The  disease has occasionally been cured naturally by a deposit
of coagula in the  sac, which, as  they have gradually increased,
have  gradually also filled up and obliterated the cavity of the sac.
Mr. Hodgson has given a curious  case  of  this kind in his treatise,
" on the  Diseases  of Arteries  and  Veins."   In  such  instances,
however, it is probable that the disease  is unconnected with an
aneurismal diathesis, and is a result of some local cause.
  Pressure, under the same circumstances of  local affection, has
sometimes  produced  a like  good  effect.   Dr.  Albers of Bremen
gives an instance of this even in an  aneurism of the femoral  artery^
It has commonly been said that the  compress should never amount
to more than an easy support to the weakened and enlarged organ :J
and it is very probable that tight  bandages, by impeding the circu-
lation in the adjoining veins  as well as arteries, have often proved
injurious    Dr.  Perceval, however,  in the manuscript  comment
with which he has enriched the  author's volume of Nosology, has
the following notice under the present head ; seeming to show that
even a tight compress has at times  been of the  highest advantage ;
and a like success is related by Acrel  in an aneurism of the aorta.5
"In  the rebellion  of  1798,  an  officer received a  wound  from a
bayonet  which  grazed the  left carotid artery and produced  a

           * Reinesius, Scliola Ictormn Medica, p. 321.
           t Trans, of Medico-Chirurg.  Soc.  Vol. ix.
           X Cagnior, Desault, Journ. de Chirurg. Tom. n.
           * Chirunjis^be Vcrfalle.  Band. i. 44% 
OE  X-SP  0       SANGUINEOUS FUNCTION.              ^




 a^XnTnhtheari, and ^f^^^^^^Z
of blood.   The heart was not found enlarged, but the cavity
left carotid was almost entirely obliterated-             frequently
   In  connection  with  pressure,  great beneht  has  also irequenuy
re ulted from keeping the amount of the circulating fluid  in a
diminished Xtby^cfasional venesections, purgatives and a spare
dirt    MoreaUi relates  a case in which  such a regimen alone
 effected a  cure when commenced early*   Yet it is obvious that in
 some habits  a cure, even  of the same artery, is obtained much more
 ea" lv than in others: and hence it seems sometimes to have taken
 p  Spontaneously, of which an example is given, b,-Mr^amp-
 ton in the Medico-Chirurgical Transactions ;t and by Mr. Ford, in a
 iournal of an earlier date.J                            ...  „ „„
 '  Every palliative  means  should  be  had  recourse  to  before an
 operation is resolved  upon:  for even under  the  most favourable
 circumstances such a step is hazardous, and it is peculiarly so when
 the aneurism is connected with a diseased  state of the  arterial
 trunk  or the whole arterial system,  of which it is seldom  possible
 for us to form a correct judgment.  To describe the nature of the
 operation would be  to  travel  into the  province of surgery.  1
 may, however,  observe that in cases of necessity it has often been
 performed with full success, and even a perfect use of the affected
 limb,  in  trunks  of a very  large calibre.   Mr., now Sir Astley
 Cooper, has given an account of two cases in which the  operation was
 effected on  the carotid artery.   J he, first proved unsuccessful from
 the long standing and size of the sac, which pressed with perpetual
 irritation  on the  larynx and pharynx,  exciting  frequent hts ot
 coughing, and preventing deglutition.  The second case terminated
 favourably ; but the tumour was smaller and of more recent growth.
    In the second  variety  or  diffuse  aneurism, the aneurism by
 infusion of  M.  Petit,§ the coats  of the  artery,  instead of  being
 dilated into a sac, are divided; and, the blood  flowing at large into
 the cellular or other surrounding parts, the tumour is extensive and
  undefined.
    This is usually the result of external violence : the  swelling often
 spreads to an unlimited range, and the progress towards a rupture of
  the  integuments is  more  rapid than in the last.  Here  pressure is
  of no  avail, and  even mischievous; since it will more effectually
  obstruct  the course of the blood in the  surrounding  veins, than in
  the divided artery: and  the operation can rarely be dispensed with.
  Mr. B. Bell was fortunate enough to succeed in the case of a division
* De Sed. et Caus. Ep. xvn. Art. 30, 31.
t Vol. vn. p. 341.
X Lond. Med. Journ. Vol. ix.
i D«sault, Journ. de Chirurgia, p. 321. 
j9t>                     HiEMATlCA.           [CL. III.-OR. IV.

of the great ileac artery just at its egress from the pelvis.   The
division was produced by an accidental and forcible entrance of a
pair of long-pointed scissors into  the hip.  The patient fainted from
loss of blood, and the wound on the surface was healed.   The
aneurism, however, continue!;  fresh blood was perpetually poured
forth; in six  weeks,  the tumour on the hip  became enormous, the
thigh was rigidly contracted, the bam recurvated,  the leg shrunk,
cold,  and  useless.  On making  an  incision  eight  inches long, the
blood issued  in such  torrents  that the patient  fainted,  and  was
supposed to be  dead  or dying,  but  the artery could not be traced.
At this critical moment  Mr  Bell  ran the  bistoury  upwards  and
downwards, and at once  made  the  wound two  feet long:  when
thrusting his hand to the bottom of the tumour, he felt the blood
still jutting warm from the artery, laid hold of it, and found it to be
the posterior iliac  cut through transversely.   He tied  it, and,
loosely dressing the wound,  left  the patient on a bed in the opera-
tion-room, as he was too  much reduced to be removed.   In  seven
months he was completely  restored to health, and recovered the
entire use of the affected leg.
  The third  variety or varicose aneurism  was first distinctly
pointed out by Dr.  Hunter, who  characterized it by this  name.
It  is produced  by puncturing an artery  through a vein, that lies
immediately above it and upon it, as in blood-letting at the arm, so
that the arterial blood flows from the arterial puncture, not through
the cellular substance, but into the superincumbent vein through the
corresponding venous puncture.  In this case,  the  tumour is don-
gated, taking the course of the vein, which is hereby distended and
rendered varicose.   Sometimes, indeed, where the  venous  commu-
nications are frequent, all the  adjoining veins participate  in the
distension,  and  are equally affected.   The tumour, as  in  the first
variety, disappears upon pressure ;  and, as  soon as the pressure is
removed,  the  blood issues  from  the arterial  puncture  with a
whizzing  sound and  a tremulous motion, rather  than  a distinct
pulsation.
  This is the least dangerous of all the forms of aneurism, and that
in  which pressure  may be applied most successfully.   It has some-
times produced a radical  cure ;  but in all instances so far succeeded
as  to render the operation unnecessary, provided the patient  passes
a quiet and unfatiguing life :  for it has been known  to exist twelve,
twenty, and even thirty years,  without any serious injury  to the
general health.
  The fourth variety is distinctly a constitutional affection, and
usually of considerable distress and  oppression.  It  is characterized
by an obtuse  intumescence and constant disquiet of the  praecordia;
with  a sense  of  internal weight and pulsation  increased on the
smallest  motion.  It  is the  ca idiogmus of Galen  and Sauvages;
the aneurisma  praecordiorum of many  authors, and  the  polvpus
cordis of others.  The symptoms are usually found on dissection to
proceed  from  an  aneurismal enlargement  of some part of the 
GE. X.-SP. I.]        SANGUINEOUS FUNCTION.              OMI

substance of the  heart,  or  the larger  vessels  in its  immediate
neighbourhood, sometimes accompanied with, and  perhaps produced
by, a polypous concretion; and sometimes without any such  sub-
stance whatever:  and where the larger  vessels  are affected they
are here, more than in any other variety, thickened and rendered
rigid  by  irregular  deposits of calcareous or ossific matter.
   It is found chiefly in persons of advanced age  ;  but whether  in
young or old is clearly  a result of organic debility.   It is well
observed, indeed,  by M. Rostan, that a dilatation and thickening  of
the walls of the heart, are not a  consequence of great power  or
strength of constitution  with energy of healthy  action; but  is
generally caused by that state of the arteries which is an ordinary
result of old age,  in  which they lose their natural elasticity, and
become  ossified, thick, inorganic tubes.  This ossification affects the
valves of the heart as well  as the vessels in its neighbourhood,
whence  the  heart is  perpetually oppressed, and  called upon for
increased action :  which increased  action itself is another cause of
increased thickening in the cardiac coats.
   The disease not unfrequently proceeds from a distinct cyst some-
times found in the  substance  of the heart,  as the right  auricle,  of
which an example is given by Bartholin ;* or the  left ventricle, as
stated by Dr. Douglas ;t but more usually in the arch of the aorta.
   In  many of these cases we can trace the cause; for the aneuris-
mal artery is at times as contracted in the vicinity of the sac,  as if
it had been tied by a ligature.  The aorta has, occasionally, in this
manner  been rendered altogether impervious, the circulation being
continued by an enlargement of the anastomosing vessels.^
   On  this account,  Morgagni ascribes the  disease before us  to a
narrowness of the  larger arteries as its common cause ;  and hence
explains  why it is  so frequently found among tailors,  and other
sedentary workmen §
   The medical treatment  can be rarely more than remedial.  Fa-
tigue  and great exertion  must be sedulously avoided, together  with
keen  mental  excitement.   The diet should be light, the meals and
hours of rest regular;  and the exercise should be  that of a carriage.
The bowels must  be attended to; and, where the palpitation  or
other distress is peculiarly troublesome, it may sometimes be reliev-
by camphor,  volatile alkali, and tincture of hyoscyamus.
   We may observe, before quitting  the  subject,  that  the largest
aneurisms have been those of this  quarter, and particularly of the
aorta,  as there is here the greatest force of action.   Littre gives a
description of one  of the superior trunk that ascended as high as the
ma villa ;|j and Teichmeyer of another that burst into the pericar
* Act. Hafn. iv. Obs. 47.
t Phil. Trans. Vol. xxix. 1414-1416.
X Cnoper and Travels Surgical Essays, I. p. 125.
i D.* Sed. et Caus. Ep. xxi. 49. xxvi. 31-33.
11 Mem. de l'Acart. P.oyale- des Sciences i Paris. Ann. 170T. 
598                     HJEMAT1CA.           [CL. I«.-OR. IV.

dium.* From their extent and pressure they often erode the cartila-
ginous and even bony substance of the ribs;  and La Faye relatesa
case in which a part of the sternum as well as two cartilages  of the
ribs  were hereby destroyed.?   In an enormous aneurism of the ab-
dominal aorta,  Morgagni  mentions that  the  posterior wall of the
artery  itself  was destroyed,  the neigbouring parts supplying the
place of a wall :| and in a like  aneurism  of the  thoracic branch he
found the  bones in the vicinity broken and demolished by the force
of its pressure.§
                         SPECIES II.

                    EXANGIA VARIX.

                            Qgnviv.

                  SOFT, LIVID TUMOUR OF A VEIN.

This disease  is to veins what the true or encysted  aneurism is te
arteries.  The coats of the veins are preternaturally dilated, and
more in some parts than in  others, so that a vein thus enlarged to
any considerable extent often appears to be a chain of venous cysts;
and as, contiguous veins often communicate, the enlargement is not
unfrequently  extended from one to  another till the  whole forms a
plexus of varices, and every part seems ready  to burst.  In some
instances, they are said to have  bursted.  This  assertion, however,
wants confirmation:  but if it were true, we should be  put into pos-
session of a diffused  as well as an encysted variety of veins, and the
disease  would make  a still nearer approach to that of arteries.
  This affection mostly occurs in the  veins of the lower extremities
in consequence of their being the most dependent part.   They of-
ten arise spontaneously in persons  of lax fibres ; but  are far more
frequently a consequence of undue fatigue, strains, cramps, or pres-
sure.   The most frequent cause is a pressure of the fetus in preg-
nancy against the  external iliac veins, in consequence of which the
blood ascends with difficulty from all the veins below, which become
distended and weakened by  its accumulation.
  From strains or other causes however, varices have been occa-
sionally traced in other large  veins than those  of the extremities.
Thus Tozelli discovered  it, after death, in the vena azygos ;|| and

  * Dissert, de stupendo Aneurysmate brachii, Sic. Jen. 1734.
  t Phil. Trans. N.287.
  X De Sed. et Caus. Morb. Ep. xi. 26.
  & Ep. xvn. 25-27.
  || Prima Raccoltadi Osservazioni rnedici, Firene, 1752 
GE. X.-SP. II.]
SANGUINEOUS FUNCTION.
599
 Michaelis describes one that terminated fatally in the jugular vein.*
 They are also met within the spermatic veins ; and in this position
 have very generally been  described  under the incorrect name of
 circocele or varicose rupture.  Morgagni asserts that the spermatic
 varix appears more frequently on the left than on the right side,
 from the insertion of the spermatic vein into the emulgent.t
   The best remedy in  all cases where it can be applied is a mode-
 rate, steady, and continued pressure : which, where the varix occurs
 in the legs, is easily accomplished  by  an elastic stocking, or, which
 is preferable,  a circular bandage of fine elastic flannel.   Dauter's
 plan of using cold water is also a very simple, and, where the varix
 is fresh, not unfrequently a very efficacious remedy :| but how far a
 solution of mineral acids or metallic  salts may add to its virtue, as
 recommended  by some practitioners,  the author cannot  affirm from
 his  own practice.
   From their disfigurement and great discomfort, varices have some-
 times  been attempted to  be removed  by  a division between  two
 ligatures, not widely different from the  operation for the aneurism.
 The attempt has, in several  instances, succeeded ; but it has more
 frequently failed, and a serious and far more extensive enlargement
 of the  vein  with varicose prominences has  followed, similar to  that
 which sometimes occurs in drawing blood from the arm ; of which
 till  of late years no very intelligent explanation has been given, and
 which I shall therefore endeavour briefly to illustrate.
   This singular and painful line of swelling was at first supposed to
 arise from the prick of a nerve ; but the nerves liable to be wounded
 in bleeding are mostly small and unimportant; while others are often
 pricked and wounded in many of the common operations of surgery
 without any serious consequence whatever.  The mischief has by
 other writers as Heister,  Garengeot, and  Haller, been  ascribed to
 wounding a  tendon or its aponeurosis; but unluckily for such phy-
 siologists, tendons  in other places are often torn  or wounded with
 very little inconvenience ; even the Achilles tendon, the largest in
 the  body, is frequently  broken, without any of the severe symptoms
 that sometimes arise from  blood-letting.   Besides which,  the acci-
 dent from bleeding occurs as  frequently when a person has been
 bled in a vein which has no tendon near it,  as when there is  reason
 to expect that a tendon may have  been wounded.  It happens as
 often that a swelled arm is the consequence of bleeding in the  ce-
 phalic or cephalic-median vein, as of bleeding in the basilic or basi
 lie-median.
   Mr. J. Hunter was the first physiologist who ascertained the real
 cause of the mischief before us: and traced it to a general principle
 which he laid down as  applicable to all internal cavities; namely^

  *See Richter's Chirurgische Bibliothek in loco.
  t De Sed. et Caus. Morb. Ep. xi.m. Art. 34.
J: Von dem auserlichen ortlkhen Gebranche des Kalten Wassers, &c. Leips. 1784. 
600
HjEMATICA.
[CL. HI.-OR. IV.
that when  injured or rendered otherwise imperfect, they are often
apt to inflame at the  injured part,  and to have the  inflammation
spread rapidly over their whole extent, as I  have already had an
opportunity of observing under peritonitis, puerperal fever, and on
various other occasions.  He was first led to this view of the cause
in the case  of veins, from noticing what occasionally happens to
horses.   It is no uncommon thing for hostlers, out of an unnecessary
or ill-judged care,  to bleed these animals in the neck  even when in
perfect health :  and in several  instances of this  kind Mr. Hunter
had observed that the neck swelled, and the horse died; and, on ex-
amining the nature of the disease by dissection, he found that the
cavity  of the vein was inflamed,  and  that the inflammation  had
spread along its  internal surface to the chest, sometimes even to the
heart itself.  And  he afterwards found a like effect produced in the
veins of the human arm, where inflammation had succeeded to bleed-
ing; and particularly ;n one case that occurred in St.  George's hos-
pital, being that  of a man who died suddenly on the eighth day after
having  been bled in the basilic  vein of the right arm, and having
suffered from inflammation as a consequence.  On dissecting the
arm, he found.not only that the cavity  of the vein had  inflamed,
but that the inflammation had  extended from the puncture, which
had been made by  the  lancet in blood-letting, as high  as the axilla;
proceeding also  to some distance  below the  puncture.  About the
middle of the arm the  vein had  suppurated;  and,  from the ulcera-
tion or absorption  of parts which attends abscesses, the vein was di-
vided into two ;  and each extremity, like the internal  surface of the
abscess, was irregular and jagged.
  Mr. Hunter was  disposed to think that the principal cause which
produces the inflammation of a vein after bleeding is the want of a
disposition to heal, arising either from its being exposed, or in con-
sequence of the  lips of the orifice  in the skin not being properly
brought together.   And he hence strongly advises that the sides of
an opened vein should at all times be made to approximate as accu-
rately as possible,  and that the orifice in the skin  should be drawn
to one  side of that in the vein, so as to make the skin do the office
of a valve to the venal opening.*
  There seems, however, in this  explanation to be  a  something
wanting; and I  cannot avoid thinking,  as in the case  of puerperal
fever, that there must  be at  the same time some  peculiar local or
constitutional irritability predisposing the injured part to  run into
an inflammatory action.
  It is  also perfectly clear that the tingling and shooting pains which
succeed venesection, are sometimes produced by  a partial division
of a nerve ; of which Mr. Sherwen of Enfield has  given a  very
striking example in a case that only yielded to an entire division
of the nerve by a  transverse  section above the orifice, after every
other attempt had  been tried in vain.t

  *' Edin. Med. Comment. V»l. in. p. 430.
  i- Id. Vol. v. p. 210. 
CF. X.-SP.  Ill-]      SANGUINEOUS FUNCTION.              bU I


                        SPECIES III.

                  EXANGIA CYANIA.

                        Bltte^Sfttn.

SKIN MORE  OR LEi5 BLUE J LIPS PURPLE ; GENERAL HEBETUDE, AND INAf
                            T1VITV.

This species  is designed to express that singular appearance  and
diseased state of the entire system produced by a connate communi-
cation of the two  ventricles of the heart, and consequently an im-
perfect discharge  of the carbone of the blood at the lungs which
constitute  the  proper organ of its  elimination.   From the Greek
xvxm, or " blue,"  Dr. now Sir Alexander Crichton, in allusion to the
colour of the skin by which it is peculiarly distinguished, has ele-
gantly named it cyania, and the term has been adopted, as a specific
appellation on the present occasion.
   Antecedently to birth, the lungs are of small comparative impor-
tance to the functions of life and growth, and hence no more blood
seems Jto circulate through them than is necessary for their de-
velopement and health.   The  florid, or decarbonated blood, in-
stead  of being received from the lungs  by  the  pulmonary veins,
is  received from  the placenta by the  venae cavee,  and passes for
the most  part at once  into the general  circulation, chiefly  by
means of the  foramen ovale by which the two ventricles  commu-
nicate, and partly by means of the ductus arteriosus, by which the
pulmonary artery at this time anastomoses  with the aorta; that por-
tion of blood only which escapes through this canal flowing forward
into the collapsed substance of the lungs; amounting probably to
not more than a third or  a fourth part of the whole.
   Immediately on birth, however, the plan of decarbonization is
immediately changed.  The fetal duct and foramen are closed, and
the whole  mass of blood flows black instead of florid from the venae
cavae into  the  heart, and is sent by the  pulmonary artery to the
lungs for ventilation instead of to the placenta, in which organ, by
the disengagement of the carbone with which it is loaded, and part-
ly  perhaps by the  absorption of oxygene from the respired air (for
.the subject is still  open to  controversy.) it acquires  its perfect ela-
boration and florid hue.
   It is hence  obvious that if, in consequence of any aberration from
the common law  which regulates the wonderful change that thus
takes  place in the infantine heart and its attached vessels at the
time of  birth, either of these communications should  remain open,
Ihe venous or black-blood must wholly, or in a very considerable
degree,  be thrown back  again into the  general circulation instead
of passing  to  ihe  lungs: and the minute arteries on  the  surface.
    vol. it.                  76 
602
HiEMATICA.
[CL. IH.-OR. IV.
 which give to the complexion its tinge, being filled  with the same,
 the general hue must be changed from a florid to a blue or purple,
 more or less deep according as the  pulmonary circulation is more
 or less impeded.
   It is this natural defect that constitutes the disease before us.   In
 the varicose aneurism a small  part of the florid or arterial  blood
 flows through an  accidental opening  into the veins, but  never in
 such a quantity as  to disturb the  economy of general health.   In
 cyania a much larger, but variable proportion, of the black or ven-
 ous blood flows by a physical opening into the arteries; and usually
 with serious inconvenience to the general health,  most commonly
 indeed with fatal effects.
   How far the ordinary disengagement of carbone from the blood
 may be dispensed  with, or, in other words, to what extent  these
 connate communications may remain,  and the present disease take
 place without  endangering  the life,  we have no  exact means of
 ascertaining.  Dissections  have shown us that  the  foramen  ovale
 has continued partially open to old age, without much or even any
 interference with the  common functions of health :* but  we may
 confidently assert that, whenever so large a portion of venous blood is
 thrown into the arterial circulation as to give a blue or purple tinge to
 the lips of the skin generally, all the functions will be performed fee-
 bly, and there is great danger that the infant will never reach the age
 of puberty.  There may be living power enough in the  blood to
 support the growth of the frame during the retired  and quiet tenor
 of infancy, in which there are no sudden exertions or  calls for a more
 than ordinary expenditure of sensorial power: and hence, it is no  un-
 common'thing for a child to survive the first three or four years of life
 with a skin completely blue, and consequently with a full proof that
 the foramen ovale, or the ductus arteriosus, or both, are open to a
 very considerable extent, and that not more than perhaps a third or
 fourth part of the general current of the blood passes into the lungs
 and undergoes the process of ventilation.  But  as  soon as a  more
 active period of life commences, and the child is trusted to  his feet,
 and engages, or  should engage, in the pursuits or even amusements
 of boyhood, with all its physical and moral excitements, the living
 power is  not adequate  to the demands made upon it, and  he sinks
 beneath  their oppression,  and generally expires in a fainting fit.
 There is commonly, moreover, through the short and pitiable term
 of his existence  the clearest proof of general torpitude and deficient
 energy;  every exertion is a trouble,  every stimulus produces fa-
 tigue : the muscles enlarge, but they want vigour and elasticity : and,
 so far as I have seen, the faculties  of the mind are equally blunted.
 The celebrated blue-boy described  by Dr. Sandifort, advanced farth-
 er towards an adult age than is  by any means  common.  Here the
 aorta took its rise from both  ventricles; the pulmonary artery was

  * Geschichte einer chirurg.  Privatgesellschaft in  Kopenhagen.—Bertholin.
Anal. Reform. Lib. li. cap. S. 
GE. X.-SP. III.]      SANGUINEOUS FUNCTION.
603
scarcely pervious to a small probe, and the difficulty of passing the
probe from the heart to the lungs was greater than in the contrary
direction.   The patient was affected with an asthma from his second
year and  terminated the miserable series of his sufferings in his
thirteenth*  In the case of a young  female  related  by  Morgagni
the term of life was protracted to the sixteenth year; but there ap-
pears to have been  a somewhat freer communication with the lungs,
notwithstanding that the foramen ovale was  open wide enough to
admit the little finger.   The patient, however, was sickly from her
birth, and laboured under  great  general debility; her respiration
was difficult, and her whole skin of a livid colour.!
  Life, however, for a short  time has been maintained under still
more complicated misformations of the heart, and adjoining arteries.
Mr. Standert  gives  the case of a blue-child that lived ten days, in
which the two ventricles communicated, there  was no pulmonary
artery, but its place was supplied by an artery that branched off to
the lungs  from the  aorta in the situation of the ductus arteriosus,
the blood from which was returned by four small pulmonary veins. J
And in Dr. Baillie's Morbid  Anatomy is a still  more complicated
case of a child that  lived about two months, in which the two ven-
tricles communicated, but seemed to change their respective offices;.
the aorta arising from  the right ventricle, and the pulmonary artery
from the left.   The arterious duct was also open.§
  In distressing affections of this kind the art  of medicine  is un-
available ; and all we can advise  is perfect tranquillity, a light diet,
and attention to the state of the bowels.  In  one instance, and only
one, I have seen  the blueness of the sldn gradually disappear a few
months after birth,  and the child grow stout;  evidently proving that
the morbid communication, whether in the foramen or the arterious
duct, was closed by a natural process.
                       GENUS  XI.

                      GANGRAENA.

                         Gfanfltt'tie-

THE DEATH OF  A PORTION  OF THE  BODY, WHILE  THE REST CONTINUES
                 ALIVE, OFTEN IN A SOUND STATE.

GANGRf na, sphacelus and necrosis have been hitherto used in very

     * Observationes anatomico-pathologicee, Lugd. Bat.1777. 4to.
     t De Caus. et Sed. Ep. xvi.
     X Phil. Trans. 1805, p. 228.
     } Plate vi. p. 21. 
b04;
HiEMATlCA.
[CL. HI.-OR. l\ .
indefinite senses ;  sometimes as synonyms, and sometimes as differ-
ent stages of a common disease.  And even in this last view they
have rarely preserved  their gradations with any thing  like an uni-
form consent; the whole of them sometimes expressing the highest
and sometimes an  inferior degree of  the  malady they  equally im-
port.   For reasons stated in the volume of Nosology, the  first of
these terms is here employed in a generic sense, and the two latter as
subdivisions or species included  under  it; sphacelus importing mor-
tification as it occurs in its ordinary form, with lividity, vesication,
ulceration, and  fetor;  and necrosis that insendbility and shrivelling
of the flesh which occasionally occurs  in  paralytic  limbs.  The
genus will also  extend to two other species; as the gangrene which
commences in a bone and is usually called a caries; and that pecu-
liar form of the disease which begins  insensibly in the  extremities,
and spreads without fever in an ascending direction till the affected
limbs drop off in succession.
  All these will therefore be treated of in the following order:
                                         MORTIFICATION.
                                         MILDEW-MORTIFICATIOX.
                                         DRY GANGRENE.
                                         C-tRIES.
                         SPECIES  I.

             GANGRAENA SPHACELUS.

                       ^Hovttft'Ccitfon.

   THE DEAD PART SOFT,  MOIST, CORRUPT, AND HIGHLY OFFENSIVE.

Mortification is a disease of debility; it is a total torpitude or in-
sensibility of an organ while in the possession of its ordinary fluids
and general structure, how much soever that structure  may be in-
jured,  produced by a discontinuance of the living principle that has
hitherto actuated it;  in consequence of which  the  laws of  animal
chemistry, thus far held in subjection by the superior sway of the liv-
ing power, acquire an ascendancy, a play of chemical affinities takes
place,  and putrefaction, or a decomposition  of  the organized  sub-'
stance, and a restoration of its constituent parts  to their elementary
forms,  necessarily  ensues.
   This total debility, insensibility, or torpitude, may be produced
by too much or too little action  or excitement; for the vital flame
may be supplied so rapidly as to destroy by its own  violence,  or
there may be no supply whatever.   And we are hence furnished
with the two following varieties of the disease :
1.  GANGRAENA SPHACELUS.
2.--------USTILAGINEA.
3.--------NECROSIS.
■1.  ————— CARIES, 
oE.XI.-SP.!.]        SANGUINEOUS FUNCTION.               605

       » Inductus.                Superinduced Mortification.
       ff Atonicus.                Atonic Mortification.
  The ordinary causes of the first are fever, inflammation, local vio-
lence, or severe cold.  Those of the second are old age, impure
air, scanty or innutritious  food;  and, for the same  reason, as Sir
Clifton Wintringham has observed, ossification in the arteries of the
part affected; which is, indeed, chiefly a consequence of old age.
  Where mortification ensues, upon a severe contusion or other  m-
iurv, in a person of florid and vigorous health,  and in the prime ot
life, we have  an example of the  first variety.   There is  in this
case high inflammatory action, great heat,  swelling, and pulsation ;
the vessels  are  supplied with  a  superabundance  of living  power,
(the excitability of the Brunonians,) and are in  consequence excit-
ed beyond their strength; they are hence  worn out by  the impetu-
osity  of the toil, lose their tone, and  become torpid and insensible
from  the vehemence of their own exertion.             _
   The second variety may be illustrated by the mortification which
so frequently takes place  in the  extremities of persons already  ex-
hausted by hard labour, intemperance, or advanced years, and whose
extremities are bloated and anasarcous.   Instead of a superabundant
supply of living power there is, in this case, little or no power
whatever ;  for the sensorial fluid is secreted so sparingly  as to be
 almost incapable of reaching the extremities,  and  particularly the
 lower limbs : the muscular fibres of which, however, are in  them-
 selves so irritable that a more than ordinary excitement is scarcely
 capable of rousing them; and hence they yield  to the process of
 putrefaction from a cause the very reverse of what operates in the
 preceding case.
   Under the  first form, there is more  pain and  fever, as  there  is
 more sensibility and  violence, than under the second ; and,  on this
 account, the  destructive  march is more rapid; but with these ex-
 ceptions the symptoms, which are the ordinary ones of putrefaction,
 are the same.  The  colour of the skin changes  to a dark  red, or
 livid hue;  the cuticle is separated from the true  skin by the inter-
 position of an ichorous fluid contained in  vesicles,  or bullae, or dif-
 fused generally; it bursts by degrees; and  the subjacent integuments
 are cold, black, flaccid, sloughy, and insensible ;  sanious or bloody
 discharge of a most offensive smell.
   If the sphacelus meet with no check from art or nature it spreads
 rapidly in every direction, particularly under the first variety ;  and
 more especially when aided by an impure or unventilated atmos-
 phere, of which the hospital  gangrene, as it is called, furnishes us
 with a fearful example.  " I have seen," says Dr. Hennen, "■ the
 external ear  and the palpebral destroyed in this manner as  if in a
 series of concentric circles.  Even upon surfaces barely contiguous,
 as the fingers and toes, it generally spread in a similar way; so  that

          * Comment, u' n.orbis (piibut-'ifirn, Av.  I'.'o. 54. 
606
HAMATICA.          [CL. III.-OR. IT.
 the sore which might  have been on the middle finger or toe, and
 confined entirely to it at the morning dressing, by night engaged
 the adjoining sound ones, and in less than twelve hours  more  em-
 braced the  whole foot  or  hand.   The  gangrene still advancing,
 fresh sloughs were rapidly formed, the increasing cup-like cavity
 was filled up, and overtopped by them, and the erysipelatous  livor
 and vesication of the surrounding skin gained  ground, while chains
 of inflamed lymphatics could be traced from the sores to the ad-
 joining glands; thus exciting inflammation and suppuration which
 often  furnished a new nidus for gangrene.  The face of the sufferer
 assumed a ghastly anxious appearance; his  eyes became haggard,
 and deeply tinged with bile ; his  tongue  loaded with a brown or
 blackish fur, his appetite entirely failed him, and his pulse was con-
 siderably sunk in strength and proportionably accelerated.
  During this state, Dr. Hennen adds,  that the  bravest soldiers be-
 trayed " the greatest imaginable impatience of  pain and depression
 of spirits.  Men who had borne  amputation without a groan shrunk
 at the washing of their sores, and shuddered at the sight of a dead
 comrade ; or even on hearing the report of his death, predicted
 their  own dissolution, and sunk into sullen despair.   The third and
 last stage was now fast approaching.  The surface of the sore was
 covered with a bloody oozing;  and, on lifting  up the edge of the
 flabby slough, the probe was tinged  with  dark-coloured grumous
 blood, with  which  also  its  track  became immediately  filled: re-
 peated and copious venous bleedings now came on which rapidly
 sunk the patient: the sloughs, whether falling off spontaneously, or
 detached  by art, were quickly succeeded by others, and discovered,
 on their removal, small  thickly studded specks  of arterial blood.
 At length an artery sprung,  which, in the attempt to secure it, most
 probably burst under the ligature : the tourniquet or other pressure,
 was now applied, but in vain ;  for while it checked the bleeding, it
 accelerated the death of the limb, which became frightfully swelled
 and horribly fetid.  Incessant retchings soon  came on, and, with
 cauma, involuntary stools, and hiccough, closed the scene."*
  In this extreme form  of gangrene a septic principle appears to
be developed, very highly  acrimonious and capable of propagating
 the same disease by contagion.   For not only " upon surfaces bare-
 ly contiguous" was it found to obtain an existence, but " the skin of
 other persons, although perfectly sound,  which  had  been touched
 with a sponge employed  in washing the gangrenous sores, ulcerated,
 and soon became  itself a  slough.   This, adds Dr. Hennen, was often
 observable among the orderlies and nurses."
  The  treatment belongs rather to the department of surgery than
 of medicine.  It is obvious, however, that under the above two va-
 rieties it must be greatly varied  to  meet the variety of cause  and
 constitution.  Where an  inflammatory diathesis is present, evacu-
 ants of  every kind must be had recourse  to without sparing, as ve-
* Principles of Military Surgery, 2d. Edit. 8vo. Edinb. 1310. 
 GE. XI.-SP. I.]      SANGUINEOUS FUNCTION.               607

 nesection, purging, and relaxants, while the local applications should
 consist of refrigerant epithems till the entonic action is completely
 reduced:  after which, bark and the mineral  acids, with a nutritive,
 but not a stimulant diet, should be chiefly relied upon, and, if the
 fetor be considerable, powdered  charcoal, or the  yeast, or  carrot-
 poultice  should be applied topically.   But where,  on  the contrary,
 the mortification is that of atony, the  warmest tonics and stimulants
 are demanded, both locally and generally, from the first.
    If the limb be frost-bitten, and there be  danger  of mortification
 from this source, a plan of treatment will be requisite different from
 both the above, the  advantage of which is known to every  one,
 though the principle upon which it acts has  never been clearly ex-
 plained.
    The torpitude or insensibility of the part  affected is, in this  case,
 evidently produced by the exhausting power of the cold, which de-
 stroys or extinguishes the irritable  and  sensorial principle as rapidly
 as it is supplied.  Putrefaction, however, or a decomposition of the
 organic structure, does not readily ensue because  the  auxiliaries of
 this change, and which are absolutely  necessary to its production,
 such as heat, air, and moisture,  are not present:  for  as the  parts
 become frozen they lose their moisture or fluidity, and as there is
 no breach of surface,  there is no communication  with the exter-
 nal air.  When a limb in this state is  suddenly brought before the
 fire it becomes gangrenous almost instantly; for by this mean pu-
 trefaction obtains possession of these auxiliaries; and, in its process,
 gains the start of the remedial or restorative power of nature.  And
 hence it is well known that the worst  thing that can be done  to a
 frozen limb is to bring it into such a situation.  On the contrary, if
 we give time  to this restorative  power to exert itself while we
 prevent the process of putrefaction from taking place, by keeping
 the limb very nearly in the same condition  of freezing, or  rather'
 by raising it out of this condition by slow and  imperceptible decrees
 we shall have the best chance of recovering  it to life: since we
 hereby afford an opportunity for the warm and circulating blood and
 he active principle of irritability to push forward  once more into
 he vessels of the frozen structure, which, however, weakened and
 ^v^Xr^ b—  imposed,  and  to  reSet

   The advantage of plunging a frozen  limb,  first into ice-water
 in this nTW3rdS T Water.raised J»t ^ove the freezing poinT,tid
 in this manner advancing it gradually to a common temperature i
 of general notoriety; and it  is this plan which  forms the usua
 treatment.   In what  way the  benefit is accomplished  has been a
foequent subject of inquiry ; the remarks just offered^ may perhaps
afford a  satisfactory explanation  of the  subject       Y P     P 
608                     HiEAIATICA.          [CL. IlI.-OR. IV


                         SPECIES II.


            GANGRAENA USTILAGINEA.

                  SftLimfcS&otti&catiQn.

GANGRENE DRY, DIFFUSE, DIVERGENT ; COMMENCING  IN THE EXTREMITIES^
  WITHOUT  FEVER  OR  INTUMESCENCE,  AND  SPREADING  TILL VARIOUS
  LIMBS DROP OFF IN SUCCESSION : GREAT HEBETUDE OF MIND AND  BODY J
  OFTEN WITH VIOLENT SPASMS.

Tins is the necrosis ustilaginea of Sauvages, the specific epithet be-
ing derived from the cause to which it has commonly been ascribed,
and from which, in various cases, it seems to take its rise; I  mean
the use  of grain vitiated  or poisoned by  the  growth  of parasitic
plants in the interior of the culm or straw, chiefly the " ustilago,"
u blight or mildew ;"  whence the name  of " mildew-mortifications"
among ourselves, as that of Ergot, or spur, among the French, from
the resemblance which the mildewed or blighted corn bears to the
spur of a cock, in Latin clavus, which is the name borne by this par-
asitic plant in the language of many botanists.
  Grain thus injured by some fungus  or other has been found, when
employed as food, productive of two dreadful  diseases ; to both of
which, indeed, the French have given the name of Ergot, as occa-
sioned by a common cause; as they have  also that of mal des ardent
from the burning internal heat which is felt in  either  case.   The
one of these disorders is a typhous fever, with  the  general charac-
ter  of pestis, or what Sauvages calls erysipelas pestilens, which is
synonymous  with the third variety of pestis in the present work:
the other is  the migratory gangrene before- us, which commences,
without fever, in the hands and feet, with a sense of numbness^and
external coldness, a dusky or livid cuticle, great debility of mind
and body, often violent spasmodic contractions :*  and spreads  rapid-
ly over the system, till the fingers, arms,  nose,  legs,  or thighs are
affected, and some  of them drop off spontaneously.
  Mr. Pott has described  this species, with a few slight varieties of
symptoms, at full length, but without  appearing  to satisfy himself
with any particular cause.  " Beginning," says  he, " at the extremi-
ty of one or more  of the  small toes, in more or less time it passes
on to the foot and ankle, and sometimes to a part of the leg, and, in
spite of all the aid of physic and surgery, most commonly destroys
the patient.   It is  very unlike to the  mortification from  inflamma-
lion, to that from external cold, from  ligature or bandage;  or to
that which proceeds from  any known and visible cause, and  this as
  * Morgc^i ;. De Cat:?, et Sw'. Morb. Ep. t.v. Art. xxiv.  B.es.1. San)tm:ng*l724.
i-. n. fM •. 
 GE. XI.-SP. II.]       SANGUINEOUS FUNCTION.              609

 well in its attack as in its process.   In some few instances, it makes
 its appearance with little or no pain ;  but, in  by much the majority
 of these cases, the patients feel great uneasiness through the wbole
 foot and joint of the ankle, particularly in the  night, even  before
 these  parts show  any mark of distemper, or  before  there is any
 other than  a small  discoloured spot on the end of one of the little
 toes.—Each sex is  liable to it: but for one female in whom I have
 met with it, I think 1 may  say that 1 have seen it in at least twenty
 males.   1 think, also, that I have much more often found in the rich
 and voluptuous, than in  the labouring poor; more often in great
 eaters, than free drinkers.   It frequently  happens  to  persons ad-
 vanced  in  life, but is by  no means peculiar  to old age.   It is not
 in general preceded or accompailied by apparent distemperature of
 either of the part or of the habit.
   In its severer attacks, however, the constitution seems to be ge-
 nerally  contaminated, the  mind and body become  equally debili-
 tated, there is great irritability, and a tendency to convulsive ac-
 tion.
   According to every statement this singular  disease seems to be
 connected with a diseased state of the digestive organs, from excess
 of liviDg, deleterious food, or some other cause in connection with
 great nervous debility :* and the  tendency to gangrene proceeds
 rather from a deficiency of sensorial power, rather from any mor-
bid condition of the circulating system, whether atonic or entonic.
 And, hence, we find it best relieved by free doses of opium, in con-
junction with a generous and even stimulant diet.  Bark is of no avail,
 and the local use of spiritous fomentations and cataplasms,  warm pun-
 gent oils and balsams, of as little.   Mr. Pott tried them in every form,
but without the smallest success : and at length, employing no other
 topical application than smooth soft unirritating poultices, he confin-
ed himself to the use of opium alone, of which he sometimes gave a
grain every three hours.  And under the  influence of this medicine
the progress of the gangrene has often become checked in a few
days, and  a line of  separation distinctly marked; soon after which,
the mortified parts have sloughed away, the diseased' bone dropped
spontaneously from the affected joint, healthy granulations succeeoed,
and in due time a cure has been effected.
'* Home, Facts, and Experiments, p. 81.
  Ludwig, Adversar. I. i. 1. 7. p. 188.
VOL. II.
77 
610                      HiEMATICA.          [CL. III.-OR. IV.


                        SPECIES  III.

              GANGRiENA NECROSIS.

                      33rg CJfanflrcne.

        THE DEAD PART DRV, SHRIVELLED, HARD, AND DUSKY.

This singular species of gangrene seems to proceed from  a  maras-
mus or atrophy of the affected.limb, in consequence of which, as in
the atrophy of the body at large, the animal  oil, flesh, and fluids al-
so are gradually absorbed,  and the limb becomes emaciated  and
withered.  During the progress of this change, it necessarily grows
feebler and more torpid, till at length it is no longer capable of be-
ing stimulated by the sensorial fluid, and its different parts turn dead
and rigid.  In palsied limbs, a termination of this kind is by no means
uncommon.
   In  some instances of this affection,  the blood-vessels have  col-
lapsed, perhaps become obliterated without a retention of any of the
constituent principles of  the circulating fluid, and consequently  the
withered limb has preserved something of the natural colour of the
skin.  In others, the red particles of the  blood, changed, as in  the
veins, to a dark  or  livid hue, have, to a certain degree, remained
in the vessels and given to the limb a purple or variegated dye.
And hence the species  has laid a foundation  for  the  two  following
varieties :

x  Albida.             Retaining something  of the natural colour of
   White gangrene.       the skin.
Z  Discolor.           The natural  colour  changed to livid, or a
   Black gangrene.       mixture of hues.

   It has never hitherto been satisfactorily explained how it happens
that under this kind of mortification,  or death, the parts should  not,
as  in  the preceding species, fall  a  prey to putrefaction.  Per-
haps the following remarks may  afford some clue to  this singular
exception.
   We have already had occasion to observe, under the first species,
that a frost-bitten limb does not putrefy so long as it continues  fro-
zen, because the accessaries or co-operative powers of putrefaction,
without which this  process cannot take place, are not present, such
as warmth, moisture, and a free influx  of  air.  Now  none of these
are present in the species before us, for the limb is cold, completely
emptied of its fluids, and impervious to atmospheric influence :  and
consequently there  are the same obstructions to putrefaction in dry
gangrene,  as in a limb  killed by the biting power of frost.
   So in  the burning sands of Egypt, a  buried corpse is often found,
if dug up a month or two after interment, with as few marks of pu- 
GE. XI.—SP. HI.]     SANGUINEOUS  FUNCTION.              611

trefaction.   I have said that warmth is a necessary auxiliary, but it
must be warmth to a certain degree only : for if it exceed this, all the
interior fluids will by the heat itself be raised  towards the surface,
and pass off rapidly in  the form of vapour; in consequence of which,
the animal substance whence they issue will be as destitute of mois-
ture as if it were  frozen,  and hence  as  incapable of putrefying.
Now  this is the case with a body interred in the sultry sands of the
Delta : all  its fluids are so  highly rarefied as to evaporate, and be
drunk up by the bibulous soil by which it is surrounded before any
organic decomposition takes place :  and hence  the buried corpse,
instead of crumbling into dust  is converted  into a kind of natural
mummy, some parts of which  exhibit  proofs  of that waxy fat to
which the French chemists  have given the name  of adipocire : but
no part of which undergoes  the decomposition of putrefaction.   I do
not mean that this is always the case, but that it has occurred in a
variety of instances, where the antiseptic incidents have been pecu-
liarly favourable to such an effect.
   Dr. Alix of Altenburg, gives a singular example of the second va-
riety of this species, in a  man  of seventy-two years cf age, which
commenced, contrary to its usual course, with inflammatory symp-
toms.  The back of the left hand was attended with heat, swelling,
and pain, accompanied with thirst, a smart fever, and delirium.  At
the time Dr.  Alix saw him, a -blackness had  spread  over ail the
hand, and part of the fore-arm, which were  of a gangrenous hue,
but without pain and as hard as wood.  The pulse was  small, and
the spirits low.  Amputation was advised, but not agreed to. About
six months afterwards  he saw the patient  again accidentally  : the
gangrene had spread up to the elbow-joint, the limb was still with-
out pain, the pulse  was better, and  there was  no want of appetite.
As it was not supposed the man could live long, no farther inquiries
were made about him  till a full year afterwards, when he was found
to be as firm and  stout as  ever, although he at this time laboured
under a tertian intermittent, and had lost one of his eyes.  The
gangrene had spread over the whole arm up to the shoulder-joint:
the limb still continued hard, and as black as smoked meat; but did
not emit any cadaverous smell.  In about a month from this time,
the arm dropped off spontaneously  without the least hemorrhage :
the exposed surface of the  shoulder  dried  without any discharge
whatever, and the old  man, at the time of publishing the case, four
years afterwards, was in the enjoyment of a very good share of health.*
In this instance, the small proportion of living power which conti-
nued  after the inflammation had subsided, preserved the limb  from
putrefaction ;  aided by the hard and shrunk condition  into which it
had fallen from absorption, and a paralysis of the secernents.
  Where there is no inflammation topical stimulants, and especially
of the oleaginous kind, as camphorated oils and warm balsams, with

  *  Matthrci Francisci Alix, Med. r-t Chir. Doct. Sic. Observata Chirurgicn.   Fas-
•iculus l. 8vo.  Altenburg, ITT" 
612
HjKMATICA.
[CL. II1.-OR. IV,
persevering friction, are sometimes found useful in the commence-
ment of this disease.  Repeated blisterings and setons  have also
proved serviceable, and the voltaic trough still more so, in conjunc-
tion with a nutritive and  generous diet.  But when the gangrene
has established itself, medical skill can do  nothing  more than look
on and lament its want  of power.
                        SPECIES  IV.

                GANGR.ENA CARIES.

                           tiTartrs.

THE DEAD  PART ORIGINATING IN  A PORTION  OF  THE SUBJACENT BONE :
  PAIN DEEP-SEATED,  SUPERJACENT  INTEGUMENTS  FLACCID  AND  DISCO-
  LOURED.

Bones, cartilages, and membranes  in  their nascent state are nearly
alike;  being formed in the same  manner, and exhibiting the same
kind of structure.   Membrane is  an. expansion of gelatine richly
mapped with vessels and nerves, and containing a small proportion
of albumen to give it a requisite  degree  of firmness;  cartilage  is
membrane with a  larger  proportion  of albumen to  give it  a still
greater degree of firmness;  and bone  is cartilage hardened by an
absorption and deposit of lime through the whole of its make.  And
hence bones, notwithstanding their solidity,  possess the same living
power and are subject to the same diseases as the soft parts.
  Like the soft parts, therefore, they  are subject to  a cessation or
loss of this living principle, and the disease is,  in  this case, usually
called a caries, a Latin term,  probably derived  from the Hebrew
rH3 " ^  dig into, penetrate, or erode," "• to scoop, or hollow out."
It may originate in a bone itself, which  constitutes a  proper caries;
or it may  be communicated from a superjacent ulceration, in which
form it is  more correctly denominated a carious ulcer.
  The history and treatment of caries belong rather to the  depart-
ment of surgery than of medicine ;  and are to be learnt from writers
on this branch of the profession who have expressly treated of it;
among whom may  especially  be  mentioned Wiseman,* Petit,t and
Monro,J particularly the  last, as his learned and ingenious essay  on
this subject ought to engage the attention of every one.  The  re-
marks, therefore, to which  the author  will limit himself, will be
general and pathological, and  as summary as possible.
* Surgery. Book n. Ch. 7
t Maladies <<es Os. Tom. n. Ch. 16.
t F.ciin. Merl. Essays, Vol. v. p. 27P 
GE. XI.-SP.~IV.]     SANGUINEOUS  FUNCTION.             613

  Most of the causes that produce a gangrene in the soft parts may
produce a caries or gangrene in the bones:  as external injuries,
cold, and a deficiency of nutrition in consequence of old age or dele-
terious food.  It is also not unfrequently produced by some acrimo-
nious or poisonous principle lurking  in the circulation, as that of
lues, porphyra, or scrophula.
  It is usually first ascertained where there is no  external  ulcer,
by an obtuse and deep-seated pain which appears to issue  from the
bone ; an  exostosis or protuberance of the bone, or periosteum in the
part affected;  tenderness to the  touch; a  loose and flabby  feel of
the superincumbent integuments, and a discolouration  of the skin.
On being laid bare it evinces all the different modifications of spha-
celus which we  have just noticed in  the soft  parts: for it is some-
times moist  and  worm-eaten, forming  the  caries vermouilti  of M.
Pent, the  cells being filled  with a corrupt sanies or- spongy carun-
cles, so that the whole assumes a quaggy appearance ; and  some-
times dry  and wasted:  and the dry variety, as in necrosis, is some-
times of a pale white, and sometimes of a black or livid hue.  And
hence M.  Petit has subdivided the  disease into  four distinct species
or varieties, founded on these remarks, but into which we  have not
space to follow him   The dry caries is generally the most superfi-
cial, and consequently exfoliates most easily;  the  history and laws
of which very curious process, we have already pointed out  under
the genus  apostema ; for the economy pursued  by nature in the  se-
paration and remorai of a dead soft  part, is precisely  the  same as
that pursued in the separation and removal of a  dead portion of
bone.  The ancients attempted to  expedite this by various means,
some  of which were puerile ;  but others far more worthy of notice :
particularly  the  destruction of the integuments by the potential cau-
tery, and afterwards an application of the actual cautery to thedead
bone  itself.   Celsus gives  a  detailed account of this operation,
which, when the caries was deep, was accompanied with numerous
periorations into the bone,  into  each of which the hot  iron  was
passed in  succession.
   When the restorative power of art or of nature has succeeded in
forming a healthy line  of separation,  and  detaching the dead part
from  the living, the former  is usually thrown  off in  a cylindrical
plate; and before the exfoliation is  accomplished, we are  able to
hear, as Severinus  has  justly remarked, a  shrill sound  whenever
the carious plate is struck with a probe, as if it were hollow.   Soon
after  this  the edges of the exfoliating part  rise a little, and a little
pus or even blood is easily pressed out at  the  margin. Here  also
granulations begin at this time  to appear, which spread  over the
sound bone underneath, and seem to  assist the  dead plate above, so
that it gradually becomes loose, and can  soon afterwards be taken
away without violence.
  The dead part of a bone is sometimes  separated  and thrown ott 
614
H^MATICA.
[CL. HI.—OR. IV.
 to a very great extent, and especially in the cylindrical bones.* The
 whole body of the tibia has in this manner been  occasionally de-
 tached by nature from its extremities, and its place supplied by  a
 vicarious callus  which has run  down the whole of the  interior
 groove hereby produced, and acquired  the hardness  of bone.   Se-
 veral  cases  of this  kind are given  in the  Edinburgh  Medical
 Essays ;t in one of which the caries  appeared  in both legs:  the
 total tibia of one limb, as the  writer Mr. W. Johnston  of Dumfries,
 informs us, being separated and  thrown off at once; while that of
 the other was detached in small pieces, and thrown out gradually.
 In five months from the removal of the  entire tibia  the patient,  a
 boy of eleven years of age, was able to walk without crutches,  con-
 tinued well  afterwards, and was fit for any country work ; the legs
 being straight, with only a little thickness at the ancles.  Justamond
gives a similar case of the humerus, and Sherman of the thigh-bone.
 I have occasionally seen this  natural  process imitated successfully
both in the tibia and  the  bones of the  fore-arm, and the diseased
part taken out  by a saw; by which process a very long period of
pain and confinement  has  been saved to the patient.
  If the caries commence in  the  internal lamina*, the superjacent
sound part has sometimes been opened through its  whole length by
the trephine applied  in a line  of  succession : the  carious part has
thus obtained an  easy exit as soon as detached, and the entire bone
has soon been renewed.  The humerus was thus treated successful-
ly in the case of  a negro-boy, as related by Mr. Walker to Mr. Else,
in the Medical Transactions.!
  A caries of the spine from  the tumid, and, so to speak,  inflated
appearance  of the superincumbent integuments, was  formerly  de-
nominated spina ventosa : and the term has, with great inconsistency,
been since applied by many writers to all bones  whatever  affected
in the same  manner, and particularly those of the tarsus and  carpus ;
 as it has  by  others been applied, with equal incorrectness, to a gene-
ral softness or flexibility of the bones,  as in Tparostia flexilis, or cyr-
tosis.
  In vertebral  caries, Mr.  Brodie has given cases which  make it
probable  that here also  the  disease sometimes  commences in the
bones, and sometimes in the intervertebral cartilages ; for  in vari-
ous instances the loss  of substance was greater in the former, and in
others in the latter.§

     * Bartholin. Art. Hafn. Obs. 1.
       Nicholai, Diss. Observ. quajdam Medico-chir. Jen. 1786.
     t Vol. i. p.  192-4.  Vol. v. p. 370.
     X Vol. in. p. 27.
      * Observations on Diseases of the Joints. 
GE. XII.]          SANGUINEOUS FUNCTION.                615


                     GENUS  XII.


                          ULCUS.



 K PURULENT OR ICHOROUS SORE,  PRODUCED BY THE SEPARATION OF A
                          DEAD PART.

This genus of diseases is, in every species, a subject of manual at-
tention, and chiefly to be remedied or cured by external means. Its
mode of treatment, therefore, must  be  learned under a course of
surgical lectures:  and it  is only noticed in  the  present  place to
show the exact station which it  ought to  bear in a general system of
nosology founded on a physiological basis.   Ulcus is, strictly speak-
ings Greek term with a mere change of one convertible vowel for
another, to give  it more of a Latin form ; the derivative noun  be-
ing eA*«$, probably, as conjectured by Eustathius, from tXxa, " tra-
ho," in the sense of " distraho," hereby  producing what the Greeks
called a *««■«« o-vvtx,uxt, which is literally a " solution of continuity."
  Ulcers have  been treated of by different writers under a great
variety  of divisions and subdivisions ; sometimes as being connected
with the state of the constitution, or as being a  mere local disease;
sometimes as recent or  chronic; and sometimes as mild or malig-
nant ; but, as local ulcers may  become  constitutional, the constitu-
tional may  assume various forms, the recent be rendered chronic,
and the  mild and malignant change places, none of these characters
are calculated for clear or permanent distinction.  And hence anoth-
er principle has been appealed to in the  volume of Nosology deriv-
ed  from the variety of their external  form, and they  have  bees
contemplated under the following species :
1. ULCUS 1NCARNANS.             SIMPLE  HEALING ULCER.
2.-----VITIOSUM.               DEPRAVED ULCER.
3.-----SINUOSUM.               SINUOUS ULCER.
4.-----TUBERCULOSUM.          WARTY EXCRESCENT ULCER.
8.-----CARIOSUM.              CAKIOUS ULCEB.
                         SPECIES I.

                 ULCUS  INCARNANS.

                  Stmjrtc  hcnlfng SUlcer.

  THE DISCHARGE PUKULENT, THE SURFACE HEALTHY AND GRANULATING.
When an ulcer assumes this form it is hardly to be called a disease ;
being nothing more than the  ordinary process of the instinctive or
remedial power of nature  to restore  the  substance  that has been 
616
H^MATICA.
[CL. 1H.-OR. IV.
lost by external violence, or some internal morbid action, and to en-
dow it with the same attributes of vascularity, feeling,  and motion.
It is to this form that all the other species of ulcer must be reduced
before a cure can be  accomplished or even hoped for.  Even the
surgeon  has  here little upon  which to employ  himself; for with
cleanliness,  a  light and easy dressing, plain,  unirritating diet, and
regular hours, the processes of incarnation and cicatrization, wb.cb
we  have already ext-ia'ned under the genus apostema, will proceed
spontaneously, and without obstruction,  and a cure be speedily com-
pleted.
                         SPECIES  II.

                   ULCUS  VITIOSUM.

                      15 yratatt  &lcer.

             WITH A VITIATED SURFACE AND SECRETION.

This degenerate condition exhibits  itself under various  forms, and
results from various causes.   The modifications most worthy of no-
tice are the following:

* Callosum.                The edges indurated and retracted.
  Callous ulcer.
C Spongiosum.             With fungous or spongy excrescences.
  Fungous ulcer.
y Gaucrosum.              With a  hard, livid, lancinating irregtt-
  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. II.]    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 diflicult
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  we 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 constitu-
tional 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 which 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 when 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 le°s than might be expected.
   vol. n.             78 
618
h;ematica.
[CL. III.-OR. IV.
  The cautery thus prepared and applied, has been frequently found
the most effectual as  well as the shortest means of extirpating can-
cerous schirrosities 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 hema-
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  which con-
taminates the parts adjoining, whether gland, muscle, cellular mem-
brane or periosteum, and  converts them  into its own nature.  At
the same time it erodes the  skin and soon sprouts above it in a loose,
luxuriant and cauliflower 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 without destroy-
ing the  organ from  which 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 powder 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  III.

                  ULCUS  SINUOSUM.

                      Stuuous  aaiccc.
COMMUNICATING WITH THE NEIGHBOURING PARTS BY ONE OR MORE CHANNELS.

We have already 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 
1
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 with 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.
x Recens.                    The channel fresh and yielding.
  Recent Sinus.
C 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  re-
 course  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 or nerves, is by far the speediest
 aud most decisive of the whole.
                        SPECIES  IV.

              ULCUS TUBERCULOSUM.

                Warts SSrcrcscntt Ellcer.
WITH  TUBERCULOUS EXCRESCENCES, LOBED  BY RAGGED AND  SPREADING
                        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 
t
620                    HvEMATICA.            [cL. HI.-OTt. 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 practicable  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 Sauva-
ges denominates it cancer Lupus.   It commences in the subjacent
periosteum or perichondrium  from a diseased condition of the or-
gan; at first assumes  externally the form of a  tubercule or wart;
and though found  over the body generally, is most  common to the
eje-lids, nostrils,  cheeks,  and other parts of the face. At is highly
irritable ;  and when  the tubercle has acquired  the size of a fig or
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 se-
creted  below, an herpetic  vesication is formed on the surface.
  If partially extirpated, it grows again with rapidity and to a grea-
ter extent; caustics always exacerbate it; and the only radical  cure
consists in dissecting the diseased  part, and removing the whole of
the periosteous or  cartilaginous base as  far as it appears to be af-
fected.
                        SPECIES V.

                  ULCUS CARIOSUM.

                      <£arious Wllttv.
 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 we have already observed, a caries
properly so  called.   When it is destroyed by the spread of a sore
commencing in the integuments  or muscles above it, the disease  is
called  a carious ulcer.  And when 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.

                 * Vol. XLix, year 1755.
                         END OF VOL. II. 
 
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