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THE
STUDY  OF  MEDICINE.

              WITH A

  ffa^BBOlCfflnOAB. 878V0IS
               OF

         NOSOLOGY.

               BY

  JOHN MASON GOOD, M. D. P. R. S.
     HEM. AM. JFHII. SOC. AND F. L. S. OP FKILAEELFHI1*

       «N FIVE VOLUMES

             VOL. II.

         TOURTH AMERICAN EDITION
«. C. CAREY & I. LEA, E. PARKER, MAROT & WALTER, ANP
             T. DESILVER :
               AND
        COLLINS & HANNAY, NEW-YORK.
               *835.
 
/
__   ;
      gf)ilauflpfjia,
Ptinted by William Brown.
 
CLASS HI. 
           CLASS III.

        HiEMATICA.
 DISEASES OF THE SANGUINEOUS FUNCTION,
ORDER  I.
         PYRECTICA.
                FEVERS.
      II.
         PHLOGOTICA.
                INFLAMMATIONS.
      HI.
         EXANTHEMATICA.
                ERUPTIVE FEVERS.
      IV.
         DYSTHETICA.
                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 o£ 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 transcendent 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 s
insomuch that I am not  acquainted with a single  conjecture that
was ever vented upon the subject that is in the least degree worthy
ef 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, Haryey, about a century  afterwards,  gave a finish  to the 
 6                  PHYSIOLOGICAL PROEM.            [CL. HI.

 inquiry, by establishing the larger circulation, or that over the whole
 frame.
   The principal proofs of a circulation of the blood offered by Har-
 vey, and  those, indeed,  on which we  chiefly rely  in the present
 day, are deduced  from the disposition  of the valves of the  heart;
 the  range of the arteries and the veins, and from what occurs when
 either the arteries or veins are opened, compressed, tied, or injected.
 Thus, if we open an artery, the blood that jets from the puncture
 flows in a direction from the heart; and in a direction to the  heart,
 if we open a vein.   A compression or ligature upon an artery, puts
 a stop to the blood that flows from above the ligature ; but the same
 upon a vein puts a stop to the blood from  below it, in which di-
 rection the vein immediately becomes  distended.   In like  man-
 ner, an acid liquor injected into the veins  coagulates the blood in
 the  direction towards  the heart, proving that the venous blood is
 every where travelling in this course.   While an examination by
 the microscope  of the half-transparent  vessels of frogs and other
 cold-blooded animals confirms the view  laid open by these phaeno-
 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 attenuate part  of  the arterial
 blood, slightly tinged  of  an  opaline or rose-coloured hue, though
 sometimes of  a madder-red; such as the fluid which oozes upon
 puncturing the lymphatics, or the thoracic  duct  after a long fast.
 It  is not necessary to examine  into the  correctness  of this hy-
 pothesis in  the  present place, as we shall have occasion to notice
 it more at large when treating  of the excernent system,  which
 will be found to embrace both the absorbent and secretory vessels.
 It should, however, be remarked, that in M. Magendie's hypothesis
 the veins, and not the lymphatics, are the absorbents of the body.*
  Omitting  then for the present the consideration of thelimphatics,
 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 Elemtntaire de Physiologic torn, it 
CL. HI]             PHYSIOLOGICAL PROEM,                 7

first sent from this central organ to the lungs to be duly aerated, or,
according to Mr. Ellis's hypothesis, to be unloaded of its excess of
•carbone, and is afterwards returned from the lungs to the same or-
gan before  its general circulation over the  system commences.
These classes, therefore,  are said to  possess a double circulation.
And as the heart itself consists of four cavities, a pair,  composing
what is called an auricle and a  ventricle, belonging to each of the
two circulations; and as  each  of these  pairs, is divided from the
other by a strong membrane, these classes are also said to have not
only a  double circulation, but a double  heart;  a pulmonary and
corporeal circulation, and a pulmonary and  corporeal heart.
  The heart is well known to be situated in the chest between the
lungs, above the diaphragm, and to be influenced by all the motions
of the diaphragm.  It is loosely surrounded by a dense  and fibrous
membrane,  named from its situation  pericardium, possessing little
sensibility, closely connected with the substance of the diaphragm,
and reflected over the heart and its large vessels.  Its use is to con-
fine'the heart in its proper post; and to lubricate it, in its state of
unceasing activity, with a peculiar fluid, denominated liquor pericar-
dii, supposed to be secreted by peculiar  glands, but more probably
exhaled from the capillary arteries of the  internal  surface.  In a
state of health this fluid is small in quantity and of  a reddish hue,
some portion of the red parts of the blood  being intermixed with
it; but, in a morbid state of the membrane, it is apt to accumu-
late, change its properties, and lay a foundation for various com-
plaints.
   The power possessed by the pericardium  of restraining the heart
to its  proper post, is obvious from  the following fact.   If,  after
detaching the sternum  and opening the chest,  an incision be made
into the pericardium of a living animal wide enough for the pur-
pose, the heart will often be found' to leap out of its sac  through
this aperture, and to fall on the right or the left side of the thorax.
And hence  the common and  colloquial expression derived from
common feeling, of the leaping of the heart for joy—and it mi^ht
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 spjs-
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 t\  •
ounces of blood at every  jet,  the greatest force  is exerted against
the arteries that immediately issue from the heart.   Here, there- 
5
PHYSIOLOGICAL PROEM.
|CL. III.
 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 angleB
 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
 clastic 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
 weaker than in the arteries; they have, nevertheless, a more difficult
 task to perform than arteries; for, with a few exceptions, they have
 uniformly to force the current of blood upwards to the heart against
 the power of gravitation.  They are hence far more  numerously
 furnished  with valves than the arteries, by which the ascending
 columns of blood are prevented from retrograding; and have  by
 many physiologists been supposed  to possess some degree of con-
 tractile, and consequently of propulsive power, by the joint pressure
 of the sides of the arteries or muscles  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 Berzelius, militate so strongly
 against the affirmative  to  this  proposition, that  the existence of
 such fibres in both classes  of vessels has of late been doubted by
 many, and the contractility of  the arteries been  ascribed to their
 elasticity of texture  alone; while the veins are conjectured to be
 altogether passive in the change of diameter they sustain.  Yet
 whatever doubts may be entertained upon this subject in veins and
 arteries,  the existence of muscular fibres cannot  be  questioned in
 the minute vessels termed capillaries.
  I have observed, that the force with  which the blood is at first
 projected from the heart is progressively diminished by the resist- 
OL. III.]
PHYSIOLOGICAL PROEM.
9
 ance it encounters in the thick and powerfully elastic tunic of the
 trunks or large arteries into which  it is  immediately propelled.
 There are two other causes which co-operate in producing a pro-
 gressively diminishing force.  The first is  the short anglesagainst
 which the  blood has to strike at the origin of all  the  different
 branches: and the next, and most important, is the large diameter
 of the general massof 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 Hunteron
 the carotids  of camels and swans,* the very same arteries appear
 gradually to widen from the upper end or that nearest the heart to
 the lower, or that most remote.   From all which he concludes that
 the aggregate diameter  of  the arterial system forms a cone whose
 apex is the  heart.  And he  concludes, also, and most correctly,
 that this conic proportion is most obvious, increases most rapidly,
 and spreads with its broadest base in infants, or rather  in the foetus;
 for here the  main trunks of the arteries are extremely  short, while
 the capillaries are very  large, and, from the  obliteration of many
 vessels in subsequent life, more numerous than at any other period.
 It is highly probable indeed that while the aorta in childhood is not
 a fourth part of the size of the same vessel in anaduit, 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
 its 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  SO; 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 biood as it
 moves forward :  a third, and indeed the  principal reason, as suffi-
 ciently proved by Dr. Carson of Liverpool, is, the natural elasticity
or resilience  of the lungs, which,  by keeping them after death in a
state of dilation, allows the blood to accumulate here as in a vacuum.
And hence, again, the reason of the accumulation of blood which is
usually found in  the  chest after death,  as well as the empty state of
the vessels.
   This vacuity of the arteries upon death, was  one of the objections
urged very forcibly by the ancients against the circulation of the
       * On Blood, Inflammation, &c. Tart I. Sect. viii. p 170.
Vol.  II.—B 
10
PHYSIOLOGICAL PROEM.
[CL. Hi
blood,or even its following  at all the course of the arteries; and
which Dr. Harvey very unsatisfactorily replied  to, by asserting,
contrary indeed to 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  large circulation.   The aorta  possesses  more
strength, but their elasticity is  nearly equal, and the measure of
each, on  being slit, is about  3| inches: and  hence there can  be
little doubt that the quantity of blood sent back to the heart, is on an
exact balance with that which flows from it.  It is not, however, at
any time the identical blood which is thus returned to the heart;
for every organ takes from  the general current, as it visits them,
such parts and such principles as it stands in need of to support the
wear and tear of its own action ; while another considerable portion
is thrown off as we have already observed in the form of secretions
or exhalations from various emunctories that open externally, or
into internal cavities.   But the drain which is hereby produced on
the arterial blood is compensated by  the  various fluids collected
from every part of the absorbent vessels,  and by the flow of the
chyle from the digestive organs; both which are poured  into the
thoracic duct, and finally intermixed  with the  returning current of
venous blood a short time  before it reaches the heart; and in this
manner the balance of arterial and venous blood is maintained.
  With respect to the actual quantity  of blood  contained in  the
entire system, our means  of determination are so imprecise,  and
consequently the calculations, or rather the conjectures that have
been offered  upon the subject, are so strikingly  discrepant, that it
is not easy to reach a satisfactory conclusion.  It is only necessary
to state a few of the different opinions that have been  offered to
show the absurdity of several of them.  Muller  and  Abeildgaard
estimate the weight even in an adult at very little more than eight
pounds;i Borelli at 20; Planch at 28 ; Haller at 30; Dr. Young at
40 ;§ Hamberger at 80; and Keil at 100.  Blumenbach states  the
proportion in an adult healthy man to be as  1  to  5 of the entire
  *  See Dr. Carson " On the Vacuity of the Arteries after Death."  Medico
Chir. Trans. Vol. XI. Part I.
  f  See Hunter on Blood, p. 133.
  i  Blumenb. Elem. Phys. p. 4. § 6.
  §  Phil. Trans. 1309. p. 5. 
L. Ill]
PHYSIOLOGICAL PROEM.
11
weight of the body.  Yet little reliance can be placed on this last
mode of determination, on account of the great diversity in point of
bulk and weight of adults, whose aggregate quantity of blood is in
all  probability nearly alike.  The  mean  numbers,  as  those  of
Baron Haller, and Dr. Young, making the amount from  30lb.  to
40lb. appear most reasonable; and perhaps fall not far short of the
sum intended by Professor Blumenbach.   The subject requires
further examination, and a nicer estimate.
  II.  There is another question which  has also, in all  ages, greatly
occupied the attention of physiologists,  but upon which we still
remain in a very considerable degree of indecision;  and that is the
moving powers employed in the circulation; or in other words,the
projectile force by which the blood is sent forward.
  The heart forms the salient point of motion, and with its systole
or contraction the circulation commences.  But what  is it that ex-
cites the heart to contract ? One of the most  common answers to
this question in the writings of physiologists is the flow of the blood
into the ventricles.  But this is merely to  argue in a circle ; for
the question still  returns, what is it that makes the blood flow into
the ventricles ? Others have referred the cause to  an immediate
impulse from  the brain.  Now, in contractions of the voluntary
muscles there is no doubt of the existence of such an impulse, for
we are conscious of it, and assent to it; but we are neither conscious
of, nor assent to any thing of the kind in respect to the contraction
of the heart; and are perfectly sure that no such power of the will
takes  place during sleep.  It is a mere assumption; ,and an assump-
tion which can only  apply to a part of the  great animal kingdom
even during wakefulness; for, as it is only in the mammals and birds
that the nerves can be thus influenced in their passage to the heart,
the postulate does not account for the contraction or dilatation of the
heart  in other classes of animals.*
  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 alteration ;
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 moment one is finished an
* Hunter on blood, p. 148. 
12
PHYSIOLOGICAL PROEM
[CL. HI
immediate demand  taking place ;  and if prevented, as this action
is under the influence of the will, the stimulus of want is increased.
We have the stimulus of want of food  which takes place regularly
in health, and so it  is with the circulation.  The heart, we find, can
rest one stroke, but the constitution feels it; even the mind and the
heart is thereby stimulated to action.   The  constant want in the
constitution  of this action in the heart, is as much as the constant
action of the  spring of a clock is to its pendulum, all hanging or
depending on each other."*
  Mr. Hunter's " Treatise on the Blood," is a work of such sterling
merit, so rich in  its  facts,  and so valuable in its remarks  that,
notwithstanding a few nice-spun and chimerical speculations, that
occasionally bewilder it,  there  is  no book  on physiology which  a
student ought to study more assiduously.  Yet I  am much afraid
that the language now read  has no great deal  of meaning in it;
and that it does  little more  than  tell  us that the  heart contracts
because it contracts, or, rather, that the circulation takes place be-
cause it takes place.
  Few physiologists, indeed seem  to have adopted this  opinion :
and hence a far more  plausible and intelligible hypothesis has been
since offered.  This  consists in supposing the  heart to bestimi'laied
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  poure I into the
arteries, that he expresses a desire of changing the  terms arterial
and -venous blood for oxygenized and carbonized.
  That oxygene,  if introduced into the blood, would stimulate the
heart, there can be  no doubt, from numerous  experiments which
prove that a very 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, unfortunately  for Dr. Darwin's hypo-
thesis, Mr. Ellis, as we observed at some length in  the proem to the
preceding class, has advanced a variety  of arguments so stubborn
and cogent, to prove  that no oxygene  whatever is introduced into
the blood 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.
f I)e Chirurgia Infusiroa renovanda.  Aut. J. M. Keffnaudot. 8vo. Ludir
■it  1770                                      D               °' 
CL. 111.]
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 aHke 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 constraction, 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 Michclot 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  no less  than  one hundred
and eighty thousand pounds.
   There are varions 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 aterial tubes,  propagated to their terminal  ramifications, and
thence continued to the veins; but by most modern  physiologists,
to a joint  power compounded of  the action of  the  heart and the
arteries.
   M. Bichat's doctrine has of late been  incontrovertibly refuted by
one or two very  simple experiments of M. Magendie.*  Besides
which, however, it is now a well-ascertained  fact, and one that has
* Precis Elementaire de Physiologic, torn. II. p. 320. 
11
PHYSIOLOGICAL PROEM.
[CL. III.
 been thoroughly elucidated by Dr. Parry of  Bath, that no increase
 of size, or indeed change of bulk of any kind takes place in arteries
 during either the systole or diastole of the heart's ventricles in a
 state of health.*  The arteries of animals, to ascertain this point,
 have been exposed in different parts, and  to considerable lengths,
 without evincing the least apparent increase of size.   And  hence
 it is the pressure of the finger, or of some other substance, against
 the side of an artery that alone occasions pulsation, in consequence
 of the resistance  hereby made to the regular flow of the blood ;
 the alternating beat being produced by the greater momentum with
 which the current strikes against  the finger  or other cause of ob-
 struction, during the systole than during the diastole of the  heart.
   It may be still further observed, that 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 radical 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 dependent
 upon the heart alone, upon the arteries alone, or upon  a combina-
tion of the two,  has by no means proved sufficiently satisfactory, or
been sufficiently supported by evidence in respect to the entire cir-
 culation.  Under no modification does it account for the flow  of the
blood through the veins.   And in regard to the whole of the views
which have been thus far  examined, Mr. John Hunter, as I have
 already observed, was so extremely discontented, that he placed  no
more stress upon one part or organ of the sanguiferous system than
 upon another; upon  the heart than upon the  arteries;  or upon  the
arteries than upon the veins ;  regarding the whole economy as  the
 result of a sort of instinct,  to which, as just  noticed, he gave  the
 name of a stimulus of necessity : and which  opinion he supported
 by making an appeal  to insects which have no proper heart: to
 worms, most of which have no heart whatever; and  to monsters
 which have been born without a heart; whilst at the same time he
 contended that veins, at least  the larger, exhibit, under certain cir-
 cumstances, an expansile and contractile power as well as arteries.
 " I think it probable," says  he, " that where there is an universal
 action of the vascular system, the action of the arteries and  veins
  • Experimental Inquiry into the Nature, Cause, and Varieties of the Arterial
Pulse, &c.  By C. U. Parry, M.*D. V. R. S. &c.  Bath, 1816. 
CL. III.]            PHYSIOLOGICAL PROEM.                  lo

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 furnised, it must  necessarily  take  an opposit
or ascending direction.
   There  are, nevertheless,  numerous difficulties  that yet  remain
to  be explained; such as the proportion of projectile  power fur-
nished by the conducting pipes themselves; by what  means the
want of a diaphragm  is compensated  in birds  and reptiles  which
have no  such organ; and what constitutes the  projectile power m
animals that have no heart,  and consequently no double pump to
work with.
* Onbloodjp. 187. 
♦
 ig                 PHYSIOLOGICAL PROEM.             [CL. III.

   There is also another curious fact which physiology has pointed
 out, but has never hitherto been  able  to explain: and  that  is,  a
 direct communication between remote or unconnected organs, ap-
 parently, by some other channel than the circulation of  the blood.
 Something of this kind  seems to exist between the spleen and the
 stomach, the  former of which has been proved by  Sir Everard
 Home lo 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 siomach 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 intercouse; 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 doctiune ov 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 ol the finger, we are now able to de-
termine many momentous facts, relative, not merely lo the slate of
the heart, but of the general system ; and, in many cases, to prognos-
ticate upon grounds which were altogether unknown to the earlier
cultivators of medicine.   And on this  account it  is that the Greek
physicians  took but little notice of the  pulse, which, even in the
 days of Celsus, was regarded as a res fallacissima.
  The pulse is influenced  indirectly  by the general  state of the
 body, but directly by that of the heart, or the arteries,  or of both
or of the quantity of blood  which the vessels have to contain.
  In an adult male of good  health, and not too corpulent, the com-
 mon standard of  the pulse may be fixed at seventy  strokes in a
minute:  but it varies in different individuals from sixty to eighty
 !-ieing greatly affected by the temperament, and partly by the habit
 of life.  In the man of a high sanguine character it rarely sinks
 below eighty, and is often at ninety ; and in the melancholic it  sel-
dom rises above sixty, and  sometimes sinks to forty.   In idiosyn-

                    * Phil. Trans. 1811, p. 163.
                    t Ibid. p. 96. 
CL. 111.]
PHYSIOLOGICAL PROEM.
17
crasies the discrepancies is so considerable, and complicated with
other changes than those of frequency and tardiness,  that there is
no reducing them to any rule.
   Lizzari tells us of a person whose pulse was  not  more than ten
beats in a minute.*   Dr. Heberden says,  he once saw  a  person
whose pulse,  as he was told, did  not number in  the beginning
of his  illness above twelve or sixteen in a minute ; though  he sus-
pects in this  and all  other  instances, where it is below forty, that
the artery beats oftener  than it  can  be  felt;  because such slow
pulses are usually unequal in their strength, and some  of the 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  in recovery in their
once more returning  to a state  of irregularity.f  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 lo  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  rhird, 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.!.   In advanced age from the small  quantity of
sensorial power, secreted, and the general inertness of  the organs,
the pulse sinks often considerably below sixty strokes in a minute.
" I knew one," says Dr.  Heberden, " whose chief distemper was
the age of fourscore, 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 Scientific), p 265.
             f  Medic. Trans. Vol. II. Art. II. p. 29.
             * Med. Trans. Vol. H. Art. II. p. 'JP,
Vor  II.—C 
«
lg               PHYSIOLOGICAL PROEM.              [CL. lit

riage, and walk about his garden, receive company, and eat with  &
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  afford
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 dangeniof the disease :  and it measures it equally, whether the
return of tKe  beat be below the standard of health or above it.
   How far in either case the pulse may vary from its natural num-
ber without great danger, depends upon a multitude of collateral
circumstances, as the age of the patient, his idiosyncrasy, the pecu-
liar disease he  is labouring under,  and  the strength or weakness of
the system. And  hence, in  addition to the number of the pulse, we
should also attend to its degree of  fulness, softness, firmness, free-
dom, and regularity; a  critical knowledge of which can only be
learnt by experience and a nice discrimination.
   It has been highly injurious  however to  the study  of medicine,

  • De Mutatione quadam pulsus insigni.  Erlang. 1778.  V. Bald. Syll. v. 
CL. HI.]
PHYSIOLOGICAL PROEM.
19
 "hat 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
 wasDr. Heberden: " Such minute distinctions of the several pulses,"
 says he, "exist chiefly  in the  imagination of the makers,  or,  at
 least,  have little  place  in  the knowledge and cure  of  diseases.
 Time, indeed, has so fully set them aside, that most of  these names
 of pulses are now as unheard of in practice  as if they had never
 been given."*  And in forming, therefore, his prognostic of a dis-
 ease, while he appeals to the pulse merely in respect to its number,
 he draws his other grounds of decision from the nature of the ma-
 lady, and the violence of its specific signs.
   But this  is to limit  the subject to too strict a boundary;  and  to
 exclude ourselves from what, in many instances, are clear  and even
 leading diagnostics.  There  are some practitioners, and of very
 high merit too, whose fingers are no more capable of catching the
 finer distinctions of the pulse than the ears of other persons  are the
 niceties of musical sounds.   I  suspect this was the case  with Dr.
 Heberden, as it was also with the late Dr. Hunter;  of whom Mr.
 John Hunter observes, that, " though he was extremely accurate in
 most things, he could never feel that nice distinction in the pulse
 that many others did, and was ready to  suspect more nicety  of dis-
 crimination than can really be found.   Frequency  of pulsation in a
 given time is measurable by instruments; smartness or quickness in
 the stroke, with a pause, is measurable by the touch, but the nicer
 peculiarities in the pulse are only sensations in the mind. I think,"
continues this distinguished physiologist, " I have been certain  of
 the pulse having a disagreeable jar in it when others did  not per-
 ceive it, when they were only sensible of its frequency and strength :
 and it is, perhaps, this jar that is the specific distinction  between
 constitutional disease or irritation and health.  Frequency of pulsa-
 tion may often arise from stimulus, but the stroke will then be soft;
 yet softness is not  to be depended on as a mark of health, it is often
 a sign of dissolution; but then there must be other attending symp-
toms."!
   Dr. Fordyce's table of the pulse is, perhaps, unnecessarily compli-
cated; but the strength or weakness, fulness or smallness, hardness
or softness, regularity or irregularity of the pulse, are  indications
nearly as  clear as  its  frequency or slowness, and, in many  cases,
quite as diagnostic of the general nature of the disease.  Frequency
and slowness of the pulse taken by themselves, indicate little more
than the degree of irritability of the heart, or the force of the sti-
• Med. Trans. Vol. II. p. 20.
t On Blood, Part. II, Ch. iii.p. 318. 
20
PHYSIOLOGICAL PROEM.
[CL.1H
 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 and a small pulse may
 be distinguished with almost  as much ease as any other property it
 possesses; this Mr. John Hunter ascribes to the state of the arteries:
 but, if 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 ihe pulse, together with that
 Vibratory thrill  which has been  called wireness, are not quite  so
 easily learnt as its fulness  and  smallness, but a nice finger will readi-
 ly discriminate them, and  practice will point out the difference to
 every one.  These characters Dr. Fordyce makes dependent, and I
 think  with great reason, on the stale 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,f 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 sUi-
 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 celeres et frequentis.
 f Nov. Observationes circa crisium praedictiones ex pulsfi.   VVetsch Merli
cinx ex pulsu.  Vind. 1770. Vienn. 1753.          P       welscn, Medi- 
CL. HI.]             PHYSIOLOGICAL PROEM.                 ;1j

sensations and movements; and that, by the agreement and co-ope-
ration of all these distinctive powers, the life and health of the en-
tire  system are built  up and  maintained.  These principles are
developed  and defended in his  thesis " De sensu gerenice conside-
rato." published at Montpellier  in 1742.  Though arrogating the
merit of originality, they are,  however, little more than a revival
of the ancient doctrine of harmony invented by Aristoxenus, and at
one time very popular in Greece, as we learn from  Lucretius:
                   —Malta quidem sapicntum turba putarunt
           Sensum aniini certa non  esse in parte locatum;
           Verum habitum quemdam vitalem corporis esse,
           ' .ipmosus 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 fiulses ;  but his general division is into supe-
rior and inferior pulses: and this he founds on an observation that
the actions of the  parts seated  above the diaphragm,  and  of those
below, excite very different impressions on the circulatory system.
These views  are chiefly given  in  the most famous of  all his publi-
cations, entitled," Recberches sur le Pouls par rapport aux crises."t
This hypothesis became extremely popular in France and Germany,
and excited a considerable degree of attention at Edinburgh.   It is
now, however, little heard of, and is by no means worth reviving.
   In effect, a voluminous and complicated classification of pulse is
rather a proof of an active fancy  than of a sound judgement: and
though Dr. Heberden and Dr. Hunter may have thought too lightly
of this branch of  pathogomy,  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
Hoffeuuffer, 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 thorough-bass.
   Ill  To speak minutely of the constituent  principles of the
blood, would carry us too far into the regions of animal chemistry;
and I shall hence limit myself  to a very brief analysis of those that
are fixed or confinable, having  already paid  some attention to the
gasses in the physiological proem to the preceding class.

  * De Rer. Nat Lib. III. 98. See the  author's examination  of this hypothes'
and its resemblance to others of later  date, in the notes of his Translator
Lucretius. Book V. 100 and 104.
  f Paris, 1756, 8vo, 
 2:                 i'HYSIOLOGICAL PROEM.             [CL. III.

   For the first judicious account of these principles, we are indebted
 to an elaborate memoir of MM. Parmentier and Deyeux, who  ar-
 ranged them under the following heads :—I.  A peculiar aroma, or
 odour, of which every one must be sensible who has been  present
 at a slaughter-house, on cutting up the fresh bodies of oxen. 2. Fi-
 brin, or fibrous  matter. 3. Gelatine.  4. Albumen. 5. Red  colour-
 ing matter.  6. Iron. 7. Sulphur. 8.  Soda. 9.  Water.
   Still minuter and more  exact experiments have since been made
 upon particular portions  or the whole of the blood, especially by
 Dr. Marcet,* Dr. Bostock,f and Professor Berzelius,i 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.
 Bcrzelius,  " arises from  the  gelatinous appearance of  the albu-
 men; I  have never been able  to detect a particle of gelatine in
 blood, and, as far as my researches extend, I have found gelatine to
 be a substance altogether  unknown to the economy  of the living
 body, and to be produced by the action of boiling water on cartilage,
 skin, and cellular membrane;  substances which are totally distinct
 from fibrin and albumen."  It follows, therefore, that wherever ge-
 latine is found in the animal frame, it is  produced by a decomposi-
 tion and  recombination of the particles of the blood  by the action of
 the secernents.
   The sulphur detected in the blood by Parmentier and Deyeux
 does not  exist in a  free state,  but is a component part of its albu-
 men,  as  is also its  carbonc and  hydrogene, which, in consequence,
 have as strong a claim to be considered as constituent principles as
 sulphur.   It is by means of its constituent sulphur that the albumen
of blood or of an  egg, becomes capable of blackening a silver instru-
 ment  employed  to  stir it. And as  it is the albumen that is now
 known to dissolve the oxydes of mercury introduced into the blood
 in the cure of syphilis, it is probably  owing to the  sulphur of the
 albumen  that this effect is  produced; or that the oxydes of any me-
 tals introduced as medicines into the blood are dissolved;  since the
 albumen of the serum is also discovered to be a powerful menstruum
in dissolving iron, copper, and other metallic preparations.
   The iron  traced  in the blood is, in like manner, a constituent
principle of the red colouring matter, and exists in so intimate an
union with it that it cannot be detected  by the best re-agents we
possess,  till  the  composition of the colouring  matter is totally de-
stroyed by heat, or some other means.
   With these explanations we are now able to proceed to a clear
comprehension of the following brief analyses of the blood, as cor-
rected by the latter experiments of M. Berzelius, supported by those
 I have just adverted to, of Dr. Marcet and Dr. Bostock.
* Trans. Medico-Chirurg. Soc. Vol. II. p. 370.
t Id. Vol. I.           * Id. Vol. III. 
. rL. HI.]             PHYSIOLOGICAL PROEM.
   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 -5^-5- of  its weight.  It seems to  be the colouring princi-
ple ; but cannot  be separated from it as long as it continues to be
colouring matter.   This separation can only be effected by combus-
tion, or by the concentrated acids, both of which agents entirely de-
compose  the substance with which the metal is combined.   The
iron exists in the form of oxyde,  with a small proportion  of  sub-
phosphate of the same.   But the colouring matter cannot be  arti-
ficially  produced by uniting albumen with red subphosphate  of
iron.
   Fibrin, albumen, and  colouring matter,  resemble each other so
closely that they may be considered as modifications of one and the
same substance.   Each of these three substances yields, when de-
composed, but does not contain, earthy phosphates and carbonate of
lime ; for the entire blood holds in solution no earthy phosphate ex-
cept, perhaps, in two 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, in consequence of a decomposition
of the blood as it arrives at the secernents of the bones.
   Vauquelin endeavoured to separate the colouring matter from the
blood by means of sulphuric acid; but this material is not wanted,
and does not very well answer  the purpose.  A method proposed
by M.  Berzelius in another communication is much simpler as well
as more effective.*  It consists in placing the clot or coagulum  of
blood 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 thisisnot
the case; as some regions, like New South Wales; at least on this
side the Blue mountains, certain no lime-stone whatever, and others
* Ann de,Chim, et de. Pliys. V. 4?. 
2t
PHYSIOLOGICAL PROEM.
[CL. HI.
no iron nor sulphur, while all these are  .apable 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 were such mate-
rials enter largely into the natural  products of the soil ; it  is per-
haps most reasonable to conclude  that tliey  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 M< nghini,
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  art of  the animal  frame than
the colouring  matter of the blood,  is in some degree doubtful.
Vauquclin seems to  have traced it in egg-shells and oyster-shells ;
and Mr. Brande thinks he has done the sar::e in the chyle and in the
serum, and this as largely as in the colouring matter of the blood,
which, after all, he thinks contains only a very minute quantity.*
But these experiments are too indefinite, and  by no means coincide
with ihose 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 observ d 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
•iever found in  the blood of   several  classes of animals, as insects
and worms: and in those in which  they are found, they have often
no  existence in the commencement of life; for they are not disco-
verable in the egg of the chick, when the heart first begins to pul-
sate; nor are they, in any animals, pushed into the  extreme ar-
teries, where  we must suppose the serum reaches.  And hence,
whatever their value, they cannot  be regarded as the  most impor-
tant part of the blood, or as  chiefly contributing to the growth and
repair of the system.t
  Various attempts have at different times been made, to determine
the form and measure the diameter of the corpuscles of the blood,
but even this does not even seem to have been accompanied with very
great success.   Delia Torre, by applying his  microscope, detected

       * Phil. Trans. 1812. p. 112.         -f- On Blood, p. 46. 48. 
CL. III.]
PHYSIOLOGICAL PROEM.
25
them, as he thought, to be flat circles or rings with a perforation in
the centre; and Mr. Hewson ascribed to them the same shape, but
represented them as hollow or vesicular, with a dot of red colour-
ing matter in the centre instead of a perforation ; so that, if his de-
scription  could have been substantial,  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.
1 hese physiological and microscopic  fancies, however, have been
long overturned; and the general  shape of the corpuscles has^jeen
sufficiently proved to be globular, the diameter of which As'mea-
sured by the  microscopical experiments of M. Bauer, is ^55^ part
of an inch;  a dimension, however,  which has since been reduced
by Captain Kater to -j^Vo Pa«* of an inch.*  Mr. 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 lo 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 phsenomena observed in the experiments
in transfusion."  But we have a clear proof that the blood of one
species of animals differs so  much from  that of another, either in
its principles or their modification, that no  benefit can result from
transfusion, unless from like kinds to like kinds.  Thus, according
to several interesting experiments of Dr. Blundell, a dog, asphyxi-
ated by hemorrhage, may easily be  recovered by a transfusion of
blood from another  dog, but is little  or not  at all relieved if the
blood be taken from man.f
  Upon the whole, however, we cannot but regard the blood as in
many respects the most  important  fluid of the  animal machine:
from it  all the solids are derived  and  nourished, and all the other
fluids are  secreted;  and it is hence the basis or  common pabulum
of every part.  And as it is the source of general health, so it is al-
so of general  disease. In inflammation it takes a considerable share,
and evinces a peculiar appearance.  The miasms of fevers  and ex-
anthems, are  harmless to every other part of  the system, and only
become mischievous when they reach the blood: and emetic tartar,

              • Phil. Trans. 1818, p. 173, 187.               "
              f Trans. Medico-Chir. Soc. Vol.' IX. p. 86.
  Vol. II.—D 
26
PHYSIOLOGICAL PROEM.
[CL. nr.
 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 tena-
 city with which it retains it,  though often in a state of  dormancy
 and inactivity, for years or even entire generations.   For as every
 gewjvand fibre of every other part is formed and regenerated from
 the||ibd, there is no other part of the system that we can so well look
 to asM^seat of such taints, or the predisposing cause of the disor-
 ders I am now alluding to; often corporeal, as gout, struma, phthisis;
 sometimes  mental, as  madness, and occasionally both, as cretinism.
  It is hence the blood has been supposed to be alive: a belief of
 very high  antiquity, and which has been warmly embraced by Dr.
 Harvey and many others of  the first  physiologists of modern times.
 It was a favourite opinion of Mr. John Hunter, and runs through the
 whole  of his doctrines.   "That the blood," says he "has life, is
 an opinion  I have started above thirty years, and have taught it for
 near twenty of that time in my lectures.   It does not,  therefore,
 come out at present as a  new doctrine; but has 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-
 trolling its  motions, they seem very clearly  to show that  the blood
 is endowed with peculiar powers; and that, as  matter at large  is
 subject to the laws of gravitation, so the matter of the blood is  sub-
ject to the  laws of instinct.  We  may here add, in favour of Mr.
 Hunter's opinion, the  following two corollaries of Dr. Philip, de-
 duced from a large field of experiments. " The power of the blood-
 vessels, like that of the heart, is independent of the nervous system.
—The blood-vessels can support the motion of the blood after the
heart is removed."!
  Admitting these deductions to be established, the power here re-
ferred to, and capable of influencing the blood or the blood-vessels,
separately from that of the heart, and of the nervous system, must
be the  power of simple life, or of instinct, which is simple life ope-
rating by the exercise of its own laws.

      • On  Blood, p. 77.            f Phil. Trans. 1815, p. 445. 
     CLASS  III.

HiEMATICA.
                        ORDER I.


                     PYRECTICA.




iiEAT AND NUMBER OF  THE PULSE PRETERNATURALLY AUGMENTED J
  USUALLY PRECEDED BY RIGOR, AND FOLLOWED  BY PERSPIRATION J
  DURING 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
occasional absence of some that, in other instances, appear to con-
stitute  its leading features.
  There are also two other difficulties  of considerable magnitude
that the nosologist has to contend with  in laying down a  clear and
perspicuous survey of fevers ; and that is, their division or colloca-
tion, and their generic names.  But as  I have already pointed out
these difficulties, and the means by which they are attempted to be
remedied under the present arrangement and nomenclature, in the
running commentary to the order before us in the volume of Noso-
logy, I shall beg to  refer the reader to the observations there laid
down,  and shall subjoin  only one or two additional remarks upon
the same  subject.
  Although the number of the pulse as well  as the heat is preter-
naturally augmented in almost every case of fever, an extraordinary
instance is sometimes to be met with that opposes the general law,
for the most part dependent, I believe,  on a  great and sudden op-
pression of the brain: an explanation which withdraws the anomaly,
and accounts for the ordinary increase of pulsation as soon as such 
28                      HJEMAT1CA.             [CL. HI.—OR. 1.

oppression is  removed.  Thus, in the yellow fever of Antigua in
1816, the pulse, as Dr. Musgrave informs us, was, in one instance,
under forty-four.   "We almost  fancied," says he, " this unusual
softness might be constitutional: but on opening.a vein, it greatly
increased in frequency : and after the loss of a considerable quantity,
of blood, it numbered  eighty, with nearly complete  relief from
every uneasy sensation."*
  In such cases the heat of the system usually exhibits as little fe-
brile augmentation as the pulse : for  as the former is the result of
increased action, till  such increased action takes place, the heat, as
in the first stage of the  paroxysm, may  continue even below the
natural standard.
  There is  a  still more curious variation from  the general law,
which is sometimes, though  very rarely, found to take place, of
which Schenck gives a  single example lhat  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.f
  To provide for these extraordinary and anomalous  incidents by
any definition  whatever, is beyond the power of language.  They
must  be left to themselves, and will rather confirm than disturb
the definition now offered, agreeably to the maxim of the schools—
exceptio probat regulam.
  In dividing fevers  into distinct genera, I have taken the line of
demarcation from the character of their duration, as  limited to a
single paroxysm ; as composed of numerous paroxysms, with inter-
vals of intermission or perfect  apyrexy ; as composed of numerous
exacerbations, with intervals of remission, or imperfect apyrexy ;
and as composed of a single series of increase and decrease, with a
mere  tendency to  intervals of remission, without perfect apyrexy at
any time.   Other nosologists have drawn their generic distinctions
from other circumstances ;  as  their disposition or indisposition to
putridity ; their inclination to a sporadic or an epidemic  character;
the vigour and violence, or weakness and debility of their action ;
or, in the language of Dr. Darwin, the nature of  their influence on
the sensitive or irritative fibres  of the animal frame.   The  most
obvious mark, however, and that which  has  been most generally
approved, is the character of duration assumed in the arrangement
before us.   To all the  rest there are greater or less objections,
which, as I have already examined them  in the  comment just re-
ferred to, need not be repeated in the present place.
  Regulated therefore by the principle before us, fever admits of
the four following genera :—

      I.  EPHEMERA.                    DIARY FEVER.
     II. ANETUS.                      INTERMITTENT FEVER.
    III.  EPANETUS.                   REMITTENT FEVER.
    IV.  ENECIA.                       CONTINUED FEVER.
• Trans. Med. Chir. Soc. Vol. IX. p. 133.     f Lib. VI. Obs. 34. 
CL. III.—OR. I.]
SANGUINEOUS FUNCTION.
29
  To each of these belong several species, and to most of the spe-
cies several varieties, as will be noticed in their respective order.
  Some slight deviation from the ordinary  nomenclature may be
observed in the generic names above: but the reader can have no
difficulty upon this head, as he will find the changes that have hereby
been occasioned are in every instance founded upon a principle of
correctness and simplification;  and consequently calculated to dis-
entangle rather than to add to his incumbrances, and to facilitate his
progress in  the labyrinth before him.  The term  Ephemera, is,
indeed, well known to every one.  Anetus and Epanetus are Greek
terms, importing intermittent and remittent, from «v/«/w,< and fr^t*)y.t.
Enecia, from the  same tongue, denotes  continued action, and is a
derivation from «vcx?i$.
  Before, however, we  enter upon the practical part of this subject,
it appears necessary to make a few remarks  upon one or two other
questions that  have very largely occupied the attention of many
pathologists,  and especially  concerning  the proximate and remote
causes of fever; and the tendency which fever has  been  supposed
to evince of terminating suddenly, either favourably or unfavourably,
at fixed periods of its progress.
  Proximate and remote causes are rather terms of recent than of
ancient writers.   In early times the causes of diseases chiefly  con-
templated where its proegumenal or predisponent, and its  proca-
tarotic or occasional.   Thus, an hereditary taint, or habitual indul-
gence in high living, may be regarded as a  proegumenal cause of
gout; and catching cold, or an unusual exertion of muscular exercise,
may form its procatarctic cause: both of which are absolutely neces-
sary; for  it is clear that the  latter, without  the  former,  would not
produce the disease; and it  is just as clear that  the former might
remain harmless in the  constitution for years, were it not  to meet
with the co-operation of the latter, which is  often, on this account,
denominated  an exciting cause.  Generally speaking, the first was
regarded as an internal, and the second as an  external cause; and in
the instance selected they are so ; but they are not so always.
  To be acquainted with causes of this kind is always useful; and,
in guarding against the approach of diseases, it is often of the utmost
importance:  but they give us very little information upon  the real
nature of  diseases, and the mode of managing them when present.
And hence another set of causes have been  adverted to, and  have
of late been chiefly studied,  and particularly  in the case of fever.
" That only," says Gaubius," deserves the name of a physical cause
which so  constitutes the disease, that, when present, the  disease
exists; while it continues, the disease continues; when changed or
removed, the disease is altered or destroyed." It is this which con-
stitutes the proximate cause, and is, in fact, the essence of the dis-
ease, the actual source of all its effects.  The remote cause is that
which directly produces the proximate: as  a specific virus in sy-
philis, or a specific miasm in influenza, or epidemic catarrh.
  In fever we can often trace  the remote causes;  though we are 
30
HJEMATICA.
[CL. III.—OR. I.
still too little acquainted with the nature  of several of them to be
able to restrict them to a specific mode of action ; of the proximate
cause, we know but very little at present, and it will probably be
long before we shall know much more.
  Let us, however, begin with the proximate  cause as that which
has most excited the attention of physicians in  all ages.  Upon this
subject, indeed, a great deal of learned dust has been  raised, and a
greht  deal of valuable time  consumed.  Ancient speculations, tor
ihey 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 hypothesis, that rank under the
common division of  the humoral pathology.  The second has
given rise lo oilier hypotheses appertaining to the common division
of the fibrous or nervous pathology.
  The hypotheses derived from the one or the other of these sources,
that are  chiefly entitled to  attention, are  the following:  of which
the first two belong to the former division, and  the remainder to the
latter.
  I.  That of the  Greek schools, founded on the doctrine of a con-
coction  and critical evacuation of  morbific matter.
  II.  That of Boerhaave, founded on the doctrine of a peculiar vis-
cosity, or lentor of the blood.
  III. That of Stahl, Hoffman, and Cullen, founded on the doctrine
of a spasm on the extremities of the solidum vivum, or living fibre.
  IV. That of Brown and Darwin, founded on the doctrine of accu-
mulated and exhausted excitability, or sensorial power.
  V.  To which we may add that fevers have, by some physiologists,
as Dr. Clutterbuck, and Professor Marcus, been identified with in-
flammation ; and  their proximate  cause been  ascribed to  increased
action in some particular organ.
   I. It was the opinion of Hippocrates that fever is an effort of na-
ture to expel something hurtful from the  body, either ingenerated,
or introduced from without.  Beholding a violent commotion in the
system, followed by an evacuation from the skin and  kidneys, with
which the  paroxysm terminated, he  ascribed the  commotion to a
fermentation, concoction, or ebullition, by  which the noxious matter
was separated from the sound humours;  and the  evacuation to a
despumation or scum which such separation produced, or rather to
the discharge of this morbid scum from the emunctories  that open
externally.   Galen supported this view with all the medical learn- 
CL. III.—OR. I.]
SANGUINEOUS FUNCTION.
3.1,
 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 gavj*
 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 has observed, by a hemorrhage so moderate,
 as for example a few drops of blood from the nose, as to be incapable
 of carrying out any considerable portion of a matter diffused over the
 whole mass of the blood; while we are equally incapable of con-
 ceiving how such diffused  morbific matter could collect itself at a
 focal point, or pass off  at a single outlet: or of tracing in the dis-
 charge, after the minutest examination, any properties  different
 from those of blood in a state of full health
   I have observed that this hypothesis is, however, harmless enough
 when merely brought forward as a speculation.  But it has not al-
 ways been limited to this point; for it has occasionally been advan-
 ced as a practical and efficient principle; and the febrile commotion, 
52                       ILEMATICA.             [CL. HI.—OR. I

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 few
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 superabun-
dance, press forcibly into improper series of vessels, and stagnate in
the extremities of the capillaries whence the origin of the cold stage,
and  consequently of the stages that  succeed it, to which the cold
stage gives rise;* and hence those medicines which were supposed
capable of dissolving  that tenacity,  or breaking down the coales-
cence of such a state of the blood, were denominated diluents, hu-
mectants, and attenuants, whilst those of an opposite  character
were called inspissants: terms which have descended to our own
day, and are still  retained even by those who pay little atlention to
the hypothesis that  gave them  birth.
  The system of Boerhaave, therefore, consisted of an  elegant and

  • Aph.756. Comment Van Swiet.Tom.il. p. 528. Edit. Lugd. Bat. 40.1745. 
CL. HI.—OR. I.]       SANGUINEOUS FUNCTION.              .33

artful combination of both the earlier and latter doctrines of corpus-
cular physiology. Without deserting the humoral temperaments of
Galen, or the constituent elements and elective attractions of the al-
chemists, he availed  himself of the favourite notions of the corpus-
cular pathologists, their points or stimuli, their frictions, angles and
spherules, derived from the Cartesian philosophy, which were now
exercising as triumphant a sway over the animal, as over the material
system ; and interwove the whole into  an  eclectic scheme, so plau-
sible and conciliatory to all parties, that  all parties insensibly felt
themselves at home upon it, and adopted  it with a ready ascent. In
the emphatical language of M. Quesnay, it was " la medicine col-
lective."
  The most triumphant fact in favour of the Boerhaavian hypothe-
sis is, that the crust on the blood in inflammations,  and cauma, or
inflammatory fever, is often found peculiarly dense.  But as fevers
(and certainly the greater number) are found without any such crust;
and as a similar crust,  though perhaps not quite so dense, exists under
other and very different states of body,  as in pregnancy and scurvy
(porphyra), even this leading appeal  has long lost its power of
conviction : whilst the abruptness with which fevers make their as-
sault, from sudden occasional causes and  in constitutions of every
diversity, forbid the supposition that in such cases a lentor or sizy
crasis of the blood, and especially a glutinosum sfiontaneum can have
time  to be produced, however it  may exist  occasionally, and be
perhaps the source of other disorders.
  III. To this period of time, in the production of fever, and indeed
of all other diseases, the human body  was regarded as almost en-
tirely passive, a mere organic machine,  operated indeed upon by
some AUTOCRATEiA,as NUTURE,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 eternal  changes perpetually taking
place in the fluids they had to convey.  A new era, however, at
length began  to dawn upon the  world: a more comprehensive
spirit to pervade  medical study : the animal frame  was allowed to
exhibit pretensions  superior to the  inanimate, and not only to be
governed by powers of its own, but by powers which are continual-
ly and systematically from a given point operating to a preservation
of health where  it exists, and  to a restoration  of health where
it has been lost or injured.  Stahl, who  was contemporary  with
Boerhaave, and in the university of Halle in 1694, first started this
loftier and more  luminous  idea,—more  luminous, though the light
was still struggling with darkness; made  the mind the controlling
principle, and the solidum vivum, or nervous system, the means by
which it acted.   Fever, on his hypothesis, consisted in a constric-
tive or tonic spasm, in his own language spasmus tonicus, produced
by a torpor or inertness of the brain, at the extremity of the nerves,
  Vol. II.—E 
34
ILEMATl'CA.              CL. HI.—OR. !.
and counteracted by the remedial exertions of the mind, the vires
xnedicatrices 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; nd soon presented to  the world a more correct system, in
a more ttractive style; but apparently with a disingenuous  con-
cealmen  of the source from which he had  borrowed his first hints.
He omit ed 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 fierifihericus:*
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) tarn cerebri., quam cerebelli cordi destinati, inertia."f
   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,
acrisdetritas aut intropressas angulis, in sphaerulas tornando,blandi-
tium  creandi ? Non satis constat speciosam ideam aequaliter in flui-
<3am solidatnque acrimoniam quadrare.—Credibilius profectd mix-
tione  chemica  magis  quam  mechanica  rotundatione,  id  opus
perfici. 't In effect, there not  only was at this time, but had been
tor many years antecedently, a general feeling among the cultivators

fehericUi^fo^^uT1, t0m •IIL *•!'  cap'4" Bochmer. D»- <*e Spasmi Peri-
pnenci signo in febnbus continentibus.  Hal. 1765

   iPathoM 29°8-£)0 Tlie0ri&^^ Vera* Ha"€ ,1734' 
CL. HI.1—OR. L]     SANGUINEOUS FUNCTION.
35
of medicine,  that neither  the laws of animal chemistry nor of the
living fibre had been sufficiently studied for the purposes of a cor-
rect pathology :  in proof of which it may be sufficient to refer to
various articles on both subjects, inserted in the Ephemerides Na-
turae Curiosorum, published at  Frankfort,. 1648, and the  writings
of Baglivi,* and  Dr. Willis ;f and still more particularly to  Dr. Gil-
christ's elaborate treatise on nervous fevers, inserted in the Edin-
burgh Medical Transactions;^ in which last the author, following
up the hint thrown out by Boerhaave in the aphorism just quoted,
endeavours to show how well the two ideas of lentor  and spasm are
disposed to amalgamate in forming the proximate cause of fever;
the spasm consisting of an universal muscular tension, and the len-
tor being united acording to the nature of the case with inflamma-
tion, acrimony, or both; and hence often producing what he deno-
minates an alternate nisus and re-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  bis 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  of energy, seated in  the brain, but
distinct from  the mind or soul; acting wisely but necessarily, for the;
general health; correcting deviations, and supplying defects,  not
from a knowledge and choice of the means, but by a pre-establish-
ed relation between the changes produced, and the motions requir-
ed for the restoration of health; and operating therefore,  through
the medium of the moving fibres, tipon whose healthy or unhealthy
state depends the health or unhealthiness of the generaj frame:
which fibres,  he regarded with Stahl, as simple nerves, the muscu-
* Specimen de fibra motrici et morboso.
f Pathologia Celebri et Norvorum.
i Vol. IV. Art. XXIII. and Tol. V. Part. H. Art. XLVHI 
S6
H.EMATICA.
[CL. HI.—OR. L
 lar filaments being nothing more than their extremeties, 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 nutricious fluid  furnished by the
 brain, and deposited by the nerves in the interstices of their own
 fibres; the matter of which fibres is a solid*bf a peculiar kind, whose
 parts are united by chemical attraction.  All nervous power com-
 mences in the  encephalon; it  "consists in a  motion beginning in
 the brain  and propagated from  thence into  the moving fibres, in
 which a contraction is  to be produced.  The power by which this
 motion is  propagated, we name," says Dr.  Cullen, "  the Energy of
 the brain; and we  therefore consider every modification of the mo-
 tions  produced, as modifications of that energy."*  He further lays
 it down as a law of  the  economy, that the energy  of the brain is
 alternately excited and collapsed, since every fibrous contraction is
 succeeded by a relaxation: whence spasms  and convulsions  are
 motus abnormes, and consist in an irregularity of  such alternation.
 But we must distinguish in this  system between the energy of  the
 brain and  the vital fluid it sends  forth by the nerves; for while  the
 former rises and sinks alternately, the latter  remains permanently
 the same.  It is not a secretion, but an inherent principle, never ex-
 hausted, and that never needs renewal.t-
  This  hypothesis, in  its various ramifications, influenced every
 part of his theory of medicine, and consequently laid a foundation
 for his doctrine of fever.  The  proximate cause  of fever was, in
his opinion, a collapse or declination of the energy of the brain pro-
 duced by the application  of certain sedative powers, as contagion,
miasm,  cold, and fear, which constitute the remote  causes.  This
diminished energy  extends its influence over the whole system, and
occasions an universal debility; but chiefly over the extreme ves-
sels, on which it induces a spasm;  and in this spasm the cold fit is
supposed to consist.
  " Such,  however,"  to adopt the words of Dr. Cullen himself, " is
the nature of the animal economy, that this debility proves an in-
direct stimulus  to the sanguiferous system; whence by the inter-
vention of the cold stage, and spasms connected with it, the action
of the heart and larger arteries is  increased,  and continues so till
it has had  the effect of restoring the energy of the brain, of extend-
ing this energy to the extreme  vessels, of restoring therefore their
action, and thereby especially overcoming the spasm affecting them;
upon  the  removing of which,  the excretion  of sweat, and other
marks of the relaxation of the  excretories, take  place.":!
* Mat. Med. Part n. Chap. VHI. 349.
t Id. Part. II. Chap. VI. p. 223.
* Pract. of Phy. § XLVI. 
CL. III.—OR. I.]      SANGUINEOUS FUNCTION
  This relaxed or perspiratory action 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 regard the whole as a re-
gular series of actions, employed by the vis medicatrix naturae for
the recovery  of health.
  That fever in its commencement or earliest stage is characterized
by  debility of the living  fibre, or, more  closely in the words of
Dr. Cullen, by diminished energy of the  brain, extending directly
or indirectly to the voluntary muscles  and capillaries, cannot for a
moment be doubted by any one who accurately watches its phaeno-
mena.  And thus far the Cullenian hypothesis is  unquestionably
correct; as it appears to be also in supposing the cold stage to be
the foundation of the hot, and of the excretion of sweat by which
the hot  stage is succeeded.  But  it fails  in the two following im-
portant 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
 introduction of the vires medicatrices naturae, is the interposition of
 a divinity in an  epic, when no probable resource is  at hand."
    The next  striking defect that must occur to the  attentive reader
 is, that debility is here made a cause of strength ; the weakened
 action of the first stage giving rise to the increased action and re-
 excited  energy that restore the system to a balance of health: and
 here again we stand in need of the interposition of  some presen!
 divinity to accomplish such an effort by such means.
    IV. It is  not, therefore, to be wondered at that this system, with
 all its ingenuity and masterly combination, should  not have proved
 satisfactory  to  every one.  In  reality, it did not  for many  years
 prove satisfactory to every one in the celebrated school in which it
 was first propounded.  And hence, under the plastic hands of Dr.
 Brown arose another hypothesis, of which I shall proceed to give a 
38
JLLMATICA.
(CL. HI.—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 cu-
 rious by its novelty, the indolent by its facility, and every one by the
 boldnesss 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 violence  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-distinguished
 by the name  of direct debility, or accumulated excitability.
   Upon these principles, he founded the character and mode of treat-
 ment of all diseases.  They consist but of two families, to  which he
 gave the name of sthenic and asthenic; the former produced by ac- 
UL. 111.—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 flame is weak, and  scarcely  capable of being
supported; and yet the fuel is more  inflammable than in a state of
health, the  excitability is accumulated.   This scheme, therefore,
completely fails in accounting for  the origin or first stage of inflam-
matory, or, in Dr. Brown's own language, sthenic fever.
  Typhus pestilens, or jail fever, is arranged by Dr.  Brown, as an
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 inefficient. 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, and increase of energy by
rest.  And it is this principle which forms the hinge on which tufns
the more finished system of Dr. Darwin.
  Sensible of the objection that weighs equally against that part of 
40
ILLMAT1CA.
[CL. HI.—OR. I.
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 " 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
ofmaterialism.
  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 affectingorgans asso-
ciated in their actions by sympathy or long habit.  Bv  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, II. ii, 7. 
CL. III.—OU. I.]      SANGUINEOUS FUNCTION.
41
quietude whatever, and, consequently, no means of re-accumulating
irritability;  but one continued train of preternatural action and ex-
haustion,  till the system is completely worn out.  And to this ob-
jection the Darwinian hypothesis seems to be altogether without a
reply.
  It is not necessary to pursue this subject further.  Other conjec-
tures more or less discrepant from those now examined have been
offered, but they have not acquired sufficient notice, or evinced suf-
ficient ingenuity to be worthy of examination.
  V. There  are other  pathologists who have referred the proxi-
mate cause of fever to a morbid affection of some particular organ,
or set of organs associated in  a  common  function.   Thus, Baron
Haller alludes to several in his day, who  ascribed it to a diseased
state of the vena cava:* Bianchi  pitched  upon the liver,f Swalve
on the pancreas,^ Rahn on the digestive  organization  generally,§
and Dr. Clutterbuck has still more lately,  in our  own country, and
with far more reason and learning, brought forward the brain;  to
an inflammation of which organ he ascribes fevers of every kind,
regarding them merely as so many varieties of one specific disease,
originating from this one common cause.||   But this is to confound
fever with local inflammation, the idiopathic" with the symptomatic
affection.  In treating  of inflammation  uhder the ensuing Order,
we shall have sufficient opportunities of seeing  that an  inflamed
state of almost any organ, and especially of membranous organs or
the membranous parts of organs, is sufficient to excite some degree
of fever or other, and not unfrequently fever of the highest degree
of danger from its duration or violence.  And hence, the liver, the
lungs,  the stomach,  the intestines, the peritoneum, and the brain,
have an equal claim to be regarded as furnishing a proximate cause
of fever when in a state of  inflammation.
  A very  striking objection to Dr. Clutterbuck's  hypothesis,  is his
limiting himself to a single organ as the cause of  an effect which is
equally  common to all of  them.   And  on this  ground it is that
Professor  Marcus of  Bavaria, who  has  contended  with similar
strenuousness for the identity of fever and inflammation, has regard-
ed all inflamed organs as equal  causes; and is hereby enabled  to
account, which Dr. Clutterbuck's more restricted view does not  so
well allow of, for the different kinds of  fever that are perpetually
springing  before us, one organ giving rise to one, and  another  to
another. Thus, inflammation of the brain, according to Dr. Marcus,
is the proximate  cause of typhus; inflammation of the lungs,  of
                * Bibl. Med. Pr. I. p. 112.
                f Hist. Hepat. p. 112.
                $ Pancreas, &c. p. 141.
                § Briefwechsel, Band. 1. p. J5Q.
                II Treatise on Fever, 8vq,
Vol. II.—F 
U'
JI.i.MAlICA.
[CL. III.—OR. I.
hectic fevci ;  that of  ihe peritoneum, of puerperal fever;  and that
of the mucous membrane of the trachea, of catarrhal fever.
  The general  answer, however, to pathologists of every descrip-
tion who thus confound or identify fever with inflammation, whether
of a single organ or of all organs equally, is, that though fever is
commonly a symptom or sequel of inflammation, inflammation is not
uncommonly a symptom or sequel of fevers.  And hence, though
post-obit examinations, in the case of those who have died  of  fever,
should show inflammation in the brain, the liver, or any other organ,
it is by no means a proof  that the disease originated there,  since the
same appearance may take place equally as an effect, and as a cause.
Whilst a single example of  fever terminating fatally without a trace
of inflammation in any organ whatever, and such  examples  are
perpetually occurring, is sufficient to establish the existence of
fever as an idiopathic malady, and to separate the febrile  from the
phlogotic divisions of diseases.
  "A fever,  therefore,"  to adopt  the language of Dr.  Fordyce,
" is a disease  that affects the whole system ; it affects the head, the
trunk of the body, and the extremities; it affects the circulation, the
absorption, and the nervous system; it affects the skin, the muscular
fibres, and the membranes; it affects the body, and affects likewise
the mind.  It is, therefore,  a disease of the whole system in  every
kind of sense.  It does not, however, affect the various parts of the
system uniformly and equally:  but, on the contrary, sometimes one
part is much affected in proportion to the affection of another part."*
  The result of the whole,  as  observed at the outset of this  intro-
duction, is that we know little or nothing of the proximate cause of
fever, or the  means  by  which, its phenomena are immediately
produced.  In the language of Lieutaud applied to the subject be-
fore us, they are too often atra caligine mersae ;  nor have any of the
systems hitherto invented to explain this recondite inquiry, however
ingenious or elaborate, answered the purposes for which they were
contrived.
  From the proximate cause of fever let us next proceed to a few
remarks  upon its remote causes.
  Dr. Cullen, who has striven so  strongly and  so  ingeniously to
simplify the former, has made a similar attempt in respect  to the
latter.   He first resolves  all  remote  causes into  debilitating or
sedative powers, instead of being stimulant as they were formerly
very generally considered, and as they are still regarded by many
pathologists,  and especially by those who  contemplate fever  and
inflammation as identic.  Whether this position of Dr. Cullen be
correct or not, it was necessary for him to lay it down and to main-
tain it, or he must have  abandoned his system of fever altogether
which  supposes it to commence in, and be  primarily dependent'
upon debility.
   These sedative or debilitating causes he reduces to  two: marsh
! On Fever, Dissert. I, p. 28, 
CL. HI.—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 the rest; " yet even this," says he,
" is commonly only an exciting cause concurring with the operation
of human or marsh  effluvia."t
  We shall find, as we proceed, that these supplemental causes may
admit of addition;  as we shall also that they more frequently exist
as independent agents than Dr. Cullen is disposed to allow.  Yet
there can  be little doubt that the chief and most extensive causes of
fever are human and marsh effluvia.
  No great benefit, however, has resulted  from  endeavouring to
draw  a line of distinction between these two terms, and hence it is
a distinction which has been very little attended to of  late years.
Miasm is a Greek word,  importing pollution, corruption, or defile-
ment generally ; and contagion, a Latin word, importing the appli-
cation of such miasm or corruption to  the body by the medium of
touch.  There is, hence, therefore, neither parallelism or antagon-
ism, 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 or 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. XCVH.
t Id. Sect. XCH.
* Nosol. Method. CI. II. Feb. Theor. Sect. 79. 
44
HjEMATICA.
[CL. III.—OR. I
sion in the atmosphere,  but varying very considerably  in  their
degree of volatility, from that of the plague, which rarely quits the
person except by immediate contact, to that of the spasmodic cho-
lera of India, which,  as observed  when  treating of it,* works its
way, if it be really from a specific  poison, in the teeth of the most
powerful monsoons, despising equally all temperatures of the at-
mosphere, and all salubrities of district, and travelling with the rapid-
ity of the fleetest epidemy.  They are of various kinds, and appear
to issue from various sources, but  we can only discriminate  them
by their specific effects.  These are most clearly exemplified in the
order of exanthems :  in which, for some thousands of years, they
have proved themselves to be of a  determined character in all  parts
of the  world where they have been the subject of observation, dif-
fering  only in circumstances that may be imputed to season, climate,
and other external causes, or to  the peculiar constitutions of the
individuals affected.   Thus, the miasm of small-pox has uniformly
continued true to small-pox, and that  of measles to measles  ; and
neither of them has, in a single instance, ran into the other disease,
or produced any other malady than its own.
   But  can we say the same of the supposed two distinct miasms
of marsh and human  effluvia? Is it equally true that the former
have never produced any other than intermittent fever, or the latter
any other than continued ? And is  it also  equally true  that each of
these maladies adheres as  strictly to ils 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 miasm as any of the
exanthems.
  But  this is to suppose what is contradicted by the  occurrences
of every day: which  compel  us  to confess that, while we cannot
draw a line of distinction between marsh and  human effluvia  from
their specific effects, we  have no other mode  of distinguishing
them.
  Some writers,  indeed, have denied that inlermittents, 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 tiiat  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.f   But this opinion is too
loosely supported to be worthy of much attention. It is sufficiently
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. III.
| Currie. Trans. Amer. Phil. So> 
GL. III.—OR. I.]      SANGUINEOUS FUNCTION.                45

the adjoining fens  were quite  free from itr*  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."t
   And notwithstanding that it becomes us to speak with  diffidence
upon a  subject respecting which we are so much in want of in-
formation,  I may venture to  anticipate that the evidence to be
advanced in the ensuing pages upon the general nature and  diver-
sities of fever,  will show that there is  more reason for believing
that the  febrile  principle produced  by marsh and human effluvia
is a common miasm, only varying in its effects by accidental modi-
fications, and equally productive of contagion, than that  it consists
of two distinct  poisons, giving rise to two distinct fevers, the one
essentially contagious,  and the other essentially uncontagious,  as
contended  for by Dr. Cullen.
   In effect, we  shall,  I think, perceive this mysterious subject
is capable  of being,  in some degree, more clearly elucidated and
still further simplified than it has been by preceding pathologists.
   In the decomposition of all organized matter, whether vegetable
or animal, when suddenly effected by the aid of  heat and moisture,
an effluvium is thrown  forth that is at all times  highly injurious to
the health, and, in a closely concentrated state,  fatal to  life itself.
Thus, we are told by Fourcroy, that in some of the  burial grounds
in France, whose graves are dug up sooner than they ought to be,
the effluvium from an abdomen suddenly opened by  a stroke of the
mattock, strikes so forcibly upon  the  grave-digger  as  to  throw
 him  into a  state of asphyxy, if close at hand; and if at a little dis-
 tance, to oppress him with vertigo,  fainting, nausea, loss of appe-
 tite,  and tremours for  many hours:  whilst  numbers of  those who
 live  in  the neighbourhood of such cemeteries labour  under de-
jected spirits,  sallow countenances, and febrile emaciation.^:   This
 effluvium is from the decomposition of animal matter  alone; but
 the foul and stinking harmattan, when it rushes  from the south-east
 upon the  Guinea  coast, loaded  with vegetable exhalations alone,
 with which it impregnates itself while sweeping over the immense
 uninhabitable  swamps and oozy mangrove thickets of the sultry
 regions of Benin,  triumphs in a still more  rapid and  wasteful de-
 struction ;  insomuch  that Dr. Lind informs us, that the mortality
 produced  by this pestilential vapour in  the year 1754 or 1755 was
 so general, that in several negro  towns the living were not  suffi-
 cient to bury the dead; and that  the gates of  Cape Coast Castle
• Medic. Trans. Vol. III. Art. XIII.
■r On Fever. Diss. I. p. 117.
t Llemens de Chiroie, Art. Putrefaction de Substances Animal, toro-iv. 
46
TLT.MATICA.
[CL. III.—OR. I.
were shut up for want of centinels to perform  duty;  blacks  and
whites falling promiscuously before this fatal scourge.
   In this case, as in the preceding, the vapour is always accompa-
nied with an intolerable stench from the  play of affinities between
the different gasses that are  let loose by the putrefactive decompo-
sition ; and  hence it is impossible to affirm that  the mortality thus
produced is the result of any single or specific miasm operating to this
effect.   But it shows us that  the general effluvium fror#the decom-
position of all dead organized matter, whether .animal or vegetable,
is equally deleterious to health and life.
   The decomposition, however, to which we are, on the present
occasion, chiefly to direct our attention, is of a mixed kind; for the
marsh and oozy soil of inhabited countries is necessarily a combi-
nation of animal and vegetable matter.
   If this decomposition take place slowly, as in cold or dry wea
ther, and more particularly in a breezy atmosphere, not the slight-
est evil is sustained during its entire process.  And hence, in order
to render it.mischievous, and particularly in order to render it ca-
pable of  producing fever of  any kind, it is necessary that it should
be assisted by the co-operation of certain agents, many of which we
do not seem to be acquainted with, but which, so far as we are ca-
pable of  tracing  them, appear to be auxiliary to the general pro-
cess  of putrefaction, as warmth, moisture, air, and rest or stagnation.
   The simplest and slightest fever that is produced under the joint
influence of these powers, is the intermittent:  and we find these
produced where their joint  influence  is but feeble, and  where it
exists, perhaps, in its lowest stage, as in the favourable climate of
our own country; where we are not often overloaded  with equi-
noxial rains, and have not often to complain of a sultry sky or a
stagnant atmosphere.   Even here,  however,  we perceive a change
in the character of the intermittent at different seasons; for while
in the spring it usually exhibits a tertian type, in the  autumn we
find  it assume a  quartan.  And as these can only be contemplated
as varying branches of the same disease, we have thus far, at least,
reason to regard it as  produced by  a common febrile miasm, modi-
fied in its operation by a variation in the relative  proportion which
its auxiliaries, known and unknown, bear to  each other during the
vernal and autumnal seasons; coupled, perhaps, with some degree
of change produced  by the same seasons in the state of  the human
body.
   If from our own country we throw our eyes over the globe, we
shall find in  every part of it, where the  same causes exist,  that in
proportion  as they  rise  in  potency  they produce a  fever of  a
severer kind, more violent in its symptoms, and  more curtailed in
its intervals, till we gradually meet, first with no distinct intervals,
and at length with no intervals whatever; and hence perceive  the
remittent progressively converted  into intermittent and continued
fevers.  And  that  here we  have still the same miasm merely mo-
dified in  its operation  by the  varied action of its auxiliary powers 
»3L. Ill—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 either of
these forms; keeping true to the form with which they commenc-
ed; or changing one form for  another.  Such  more particularly
was the fact  in  the highly malignant yellow-fever of Antigua in
1816, as fully and admirably described by Dr. Musgrave,* and to
which we shall have occasion  to refer more particularly in  its pro-
per place.
  This disease first  showed itself during sultry weather and a quiet
atmosphere, in a swampy part  of the island, among a ship's crew
lately arrived, but from a healthy vessel,  and themselves  in good
health at first landing.   It soon  spread widely, and at length indis-
criminately  in town and country, among all ranks of conditions,
and situations, blacks  as well  as whites, the oldest settlers as well
as the newest comers.  The head was, in some cases, chiefly affect-
ed; in others the stomach, the liver, or a still different organ. Hic-
cough and black vomit were common towards the close of  the dis-
ease,  though many died without it; and recovery was no exemption
from  a second attack.
  Dr. Musgrave asserts further, 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; but then, says he, they  escaped
as generally and were not more frequently affected than those who
never entered the doors of an  infirmary.  Now as all ranks  and
conditions, blacks and whites even far off in the country, were af-
fected indiscriminately, we have no reason to  expect that those
* Medicg,<Chiriirg, Trans, Vol, IX. p. 92. 
48
HAEMATIC A.
[CL. III.—OR. 1.
whoses habit 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 though the medium
of contagion.
  I have dwelt the longer upon his subject, because it is desirable
to reconcile as much as possible the conflicting testimony of respect-
able 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 introducted
into any fresh region but by contagion.f  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  infected, no sparrow ever appeared."!
  I do not remember  to have seen this last  fact so directly affirm-
ed by any modern writer; but it is not contradicted in the course
of the controversy, and is  in perfect coincidence with the state of
the  air during  the  plague  in most places,§ and  particularly at
Athens,  as described  by Thucydides : Tfjc^piov h rm ^,ev rottwrui
«pvi6a* e7rthetipi$ cvs^jjs tytvtro- ttcti ov%' tctipuvro ovre «AA#s, ovre ntpt raovro*
  * Essay on the Disease called Yellow Fever.
  \ Observations upon the Bulam Fever, which has of late years prevailed in
the West Indies, on the coast of America, atGibralter, Cadiz, and other parts
of Spain, &c. in 8yo. 1815.
  \ Report of the Pestilental Disorder of Andalusia, which appeared at Cadiz
in the year 1800, 1809, 1810, and 1813, &c. 8vo. 1815.
  § Diemerbr. De Peste, Cap. IV. Van Swieten, ex prof. Sorbait, in sect.,',1407. 
CL. Ill—OR. I.]     SANGUINEOUS FUNCTION.
49
 ovfti. O] <5V Kvvcg iajiXXov ctto-Ovrtv irotpei%o]> rov cnrojixtvovTO{,2'icLTo %vvfocti-
 TMo-Sai* 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 animam ponebant in omnibus segre :
            Extorquebant enim vitam vis morbida membris.f
            Nor longer birds at noon, nor beasts at night
            Their native woods deserted;  with the pest
            Remote they languish'd and full often died.
            But chief the dog his generous strength resign'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 us
 was in some regions contagious, or produced from human effluvium;
 as in other regions, and underother circumstances, it was produced
 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  esta-
 blishing the question  of  its importation by a ship's  crew  from.
 Spanish America ;  and as there is no doubt in the mind of those
 wTio have not buckled  on  the armour of controversy, that this fever
 was the common fever of the Mediterranean coasts, so well described
 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. Xf. 52.
               f  De Iter. Nat. Lib. VI. 1217.
               $  Medical Sketches, passim.
V©i.  II.—G 
50
HJEMATICA.
[CL. III.—OR. J
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  felt
themselves compelled to deny that it has sprung from marshy
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 modi-
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 typhus  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 organised 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 deli-
 rium, 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 sank, 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
  icterodes, or yellow typhus.
    In like manner, where the yellow fever has commenced originally
  from contagion, or in other words from a decomposition of human
  instead of marsh  miasm,  it has  been under the  very  same
  auxiliaries of filth,  poverty, crowded numbers, and  a stagnant
  atmosphere, that gives rise to typhus. Thus the fever of Malaga, of 
m'/L.IIL—OR. I.]
SANGUINEOUS FUNCTION.
51
 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 Cadis 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  toge-
 ther.  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
 Arejufa  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 of 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
Diseases, 4to. New York, 1815. 
52
HiEMATICA.
[CL. HI.—OR. I
the application of the term epidemic to any of the febrile  diseases
hereby  produced, provided this epilhet 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
such impure  air is less, while those who reside  in the  pure air of
the country are mosi liable, to  he 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  slratum of human
intercourse.
   Upon this explanation it is  not necessary to suppose that febrile
miasm  has a power either of  concentrating  its virulence, so as to
render it more active; or of multiplying its  own form, so  as to in-
crease its numerical strength; against both which  views, there are
weighty objections.  Every distinct  particle thus suspended, and
withheld from dissolution, becomes an active individual in the field
of battle, and is almost sure to grapple with its man.   So that
hereby  alone we have a  force  equal to any degree of mortality that
can be conceived.
   While then the remote causes of fever are of  different kinds, its
chief and most effective is febrile miasm; the origin  and laws of
which,  so far as we  are at present acquainted  with it, may be  ex-
pressed in the following corollaries:
   1.  The decomposition of dead organized matter, under the influ-
ence of certain agents,  produces a miasm that proves a  common
cause of fever.
   2.  The whole of these agents have not yet been explored; but so
far as we are  acquainted with them,  they seem to be the  common
auxiliaries of putrefaction, as  warmth, moisture,  air, and rest, or
 stagnation.
* Letter to Haygarth, 
CL. HI.—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.  And hence, the diversities of quotidians, tertians, and
quartans; remittent and continued fevers, sometimes mild and some-
times malignant.
  4. The decomposition of the effluvium transmitted from the liv-
ing human body, produces  a  miasm similar to that generated by
a decomposition of dead organized matter,  and hence,  capable of
becoming a cause of fever under the influence of like agents.
  5. The fever thus excited, is varied or modified by many of the
same incidents that modify the miasmic principle when issuing from
dead organized matter;  and hence,  a  like diversity of type and
vehemence.
  6. During  the action of the fever thus produced, the effluvium
from the living body is loaded with miasm of the same kind,  com-
pletely elaborated as it passes off,  and standing in no need of a de-
composition of the effluvium for its formation.   Under this form it
is commonly known  by the  name of febrile contagion.  In many
cases,  all the secretions are alike.,contaminated; and hence, febrile
miasm of this kind is often absorbed, in  dissection, by an accidental
wound in the hand, and excites its specific influence on the body of
the anatomist.
  7. The miasm of human effluvium is chiefly distinguishable from
that of dead organized matter, by being less volatile, and having a
power of more directly exhausting  or debilitating the sensorial
energy, when once received into the system.   Whence the fevers
generated in jails or other confined  and crowded scenes, contami-
nate the atmosphere to a less distance than those from marshes and
other swamps, but act with a greater degree of depression on  the
living  fibre.
   8. The more stagnant the atmosphere, the more accumulated the
miasmic corpuscles  from whatever source derived; and the  more
accumulated these corpuscles, the more general the disease.
   9. The miasmic material  becomes dissolved or decomposed in a
free influx  of atmospheric air; and the purer the air the  more
readily the dissolution takes place:  whence, e" contrario, the fouler
as  well as more stagnant the air, the more readily it spreads its in-
fection.
    10.  Under particular circumstances,  and where the atmosphere
is peculiarly loaded with contamination, the  miasm that affects man,
is capable also of affecting other animals.
    11.  By a long and gradual exposure  to the influence of febrile
miasm, however produced,  the human  frame becomes torpid to its
action, as it does to the action of other irritants; whence the na-
tives of swampy countries,  and prisoners confined in jail with ty-
phous contamination around them, are affected far less readily than
strangers; and, in numerous instances, are  not affected at all. 
o4
H.AMAT1CA.
[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 express-
 ed by the name of crisis.  The term is Greek, and pathologically
 imports a separation, secretion, or excretion of something from the
 body : which was in truth the meaning ascribed to it when first em-
 ployed, agreeably to the hypothesis of concoction  which we have
 just considered.   The original hypothesis is abandoned; but the
 term is still continued in the sense now offered.
   That changes  of this kind are perpetually occurring in the pro-
 gress of continued fevers, must, I think, be admitted by  every con-
siderate and  experienced practitioner.  Nothing is more common
 than to behold a  patient suddenly and unexpectedly grow decidedly
 better or worse in the progress of a fever of almost any kind, and
 pass on rapidly towards a successful or an unsuccessful termination.
   But the important question is, whether there be any particular
 periods in the  progress of a fever in which such changes may be
 expected ?  Hippocrates conceived there were; he endeavoured to
point out and distinguish them  by the name of critical days.  As-
clepiades and Celsus denied the existence of such periods; and.the
same diversity of opinion has prevailed  in modern times.
  It is not very easy to determine upon the subject in the present
day, and especially in our own country.  For, first, fever, like many
other complaints, may have undergone some change in its progress
from a like change in the nature of its remote  causes, or in the
constitution of man.   And, next, it seems to be generally allowed,
 that sudden transitions, whether regular or irregular, are more apt
to take place in almost all diseases in warm than in cold climates.
 On these grounds, it is probably a subject which will never become
 of great practical importance at home. Yet it is well worthy of atten-
tion as a question of history, and which may yet be of great import-
ance to many parts of the world.
   If we examine the phsenomena of the animal economy, as they
occur in a natural series, we shall find that they are in almost every
instance governed by a periodical revolution.   A man, in a state of
health and regular habits, generally becomes exhausted of sensorial
power within a given period of time, and requires a periodical suc-
 cession of rest: his  appetite  requires a periodical supply, and his
 intestines a periodical  evacuation.  This  tendency equally accom-
panies and even haunts him in disease; he cannot disengage himself
 rom it.  Gout, rheumatism, mania, rapidly and pertinaciously esta- 
TL. Ill—OR I.]     SANGUINEOUS FUNCTION.                55

blish to themselves periods of return.  The hemorrhoidal discharge
often does this ; and the catamenia constantly.   The same occurs in
fevers, but especially in intermittents ; for the  quotidian,  the ter-
tian, the quartan, have, upon the whole, very exact revolutions
And, though accidental circumstances may occasionally produce  a
considerable influence on every one of these facts, whether morbid
or natural, the tendency to  a revolutionary course is clear and  un-
questionable.
   Now, although Hippocrates has not appealed to this reasoning, it
forms  a foundation for his observations: and  when stript of the
perplexities  that encumber his  writings upon this subject, partly
produced by erroneous transcripts, and in a few instances perhaps
by his own irresistible attachment to the Pythagorean hypothesis of
numbers, he may be regarded as laying down the following as the
critical days of continued fever: the 3d, 5th,  7th, 9th,  11th,  14th,
 17th, 20th; beyond which it is not worth while  to follow the series,
 for it is not often that they extend further.
   In other parts of his works, he regards also  the 4th and 6th and
even the 21st as critical days ; so that in the first week, every day,
after the disease has fully established itself, evinces a disposition to
a serious change ; in the second week, every other  day; and in the
 third week, every third day.   It is not  easy  to determine why the
 21st day should be a critical day as well as the 20th.  Various con-
 jectures have been offered upon  the subject;  by some it has been
 regarded as a mistake in the Greek copy, and by others, as apiece
 of favouritism in Hippocrates for this number, inconsequence  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 rekoning 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, ihe 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.  After this period the ter-
  tian  type commences, and runs  through the ensuing week;  the.
  principal changes occur on the 9th and 11 th da/s, and would occur
  on the 13th, but that the quartan type now assumes its prerogative:
  and the  principal transitions  after the 11th, takes place on  the
  14th, instead of on the 13th; on the V7th ; and on the 20tb.   Dr 
56
H.EMATICA.
jCL. in.—OR. i.
 Cullen who has examined this subject with great attention, and
 simplified it from many of its difficulties, directly asserts that his
 own experience coincides  with the critical  days of Hippocrates ;
 and Dr. Fordyce,  who scarcely does justice  to 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 lhat  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.^  Why  the first  week of a fe-
 ver should incline to a quotidian  type rather than  to a tertain, or
 the second to a tertain rather than to a quartan, we know no more
 than we do why fevers should ever intermit, or at any  time observe
 the distinctions of different  types.  We are in total ignorance upon
 all these subjects.   We  see, moreover,  that intermitting  fevers,
 whether quotidian, tertain,  or quartan, have their paroxysms recur
 regularly in the day  time; the quotidian in the morning, the tertain
 at noon, and the quartan  in the afternoon; and that in no instance
 do the paroxysms take place at night: and we see also that  in con-
 tinued fevers, the exacerbations uniformly took place later in the
 day than the paroxysms of the latest intermittent:  for these rarely
 occur earlier than between five and six o'clock in the evening,
 while the paroxysms of the quartan return commonly before five.
 Of these interesting  and curious scenes we are spectators; but we
 are nothing  more; for we arc not admitted to the machinery behind
 the curtains.
  By some pathologists the  source of these phsenomena is sought in
 the influences of the heavenly bodies, and especially in those of the
 sun and the moon.  In ancient times these luminaries were supposed
 to produce an effect on all diseases, and especially on mania, epilepsy,
 catamenia, and pregnancy.   And when the Newtonian philosophy
 first illumined mankind with the brilliant doctrine of universal at-
 traction,  Di. 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 couldbe made, it was contemplated till towards the close of
the last century: about which time Dr. Darwin, by  interweaving it
with his new hypothesis, once more endeavoured to  raise  it into
popular notice, and gave it an air of serious importance.  Dr. Bal-
four, of British India, however, has still more  lately brought it for-
* De Homine.
f Rat. Med.  Part IV. p. 283.
i Du Prognostic dans less Maladies Aigues, 8vo. Montpel. 177%, 
t5L. Ill— 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  ex-
pected to take place (and do  in fact take place) at spring-tides, and
crises 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 ques-
tion 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 observationsof 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.
Vol. II.—H 
cj,                       HJEMATICA.            [CLT HJ.—OR. I.


                       GENUS  I.


                     EPHEMERA

                       Stars JFeiicr.

ONE SERIES OF INCREASE AND DECREASE J WITH A TENDENCY TO EXA-
  CERBATION AND REMISSION, FOR THE MOST PART AFPEAIUNG 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 essentially
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.   Some practitioners,  however, have called by  this
name a fever that has extended  for three days ; and Sauvages has
arranged this mode of fever under his own genus of ephemera.
But this is to confound  different species under  one  generic name.
Fordyce asserts, that he has often seen the ephemera commence its
attack with all the essential appearances of fever, and terminate in
eight, ten, or twelve hours.*  And hence, in defining ephemera,
the symptom of duration ought not to exceed the limit here allotted
to it.
  In this simple shape of the disease, the pathognomnic 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 ammal frame through a single diurnal revolution.  The
cold stage, however, is often scarcely perceptible, and sometimes
altogether imperceptible, the general languor takingplace 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
mariner following:

  1. EPHEMERA M1T1S.                  MILD DIARY FEVER.
  2----------ACUTA.                 ACUTE DIARY FEVER.
  3.---------SUDATORIA.             SWEATING FEVER.
• On Simple Fever, Diss. I. p. 33. 
GE. I.—SP. I.}      SANGUINEOUS FUNCTION.
                          SPECIES I.

                   EPHEMERA  MITIS

                     $min Btarg jpcber.

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

 The common exciting causes are, excess of corporeal and especially
 of muscular exertion; long protracted study ; violent passion; sup-
 pressed perspiration; sudden heat or cold.
    There are few  persons who have not felt this species of diary
 fever  at times, from one or other of the causes just enumerated;
 When a man has  worked himself up into a violent and long conti-
 nued fit of wrath,  whether there have been reason  or no reason,
 and more especially in the 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 outlet of the
 attention ;—and when, beyond this, he still  urges his abstruse and
 protracted train of thought into a late  hour of the night or the
 morning—there is a general  irritation or undue excitement  pro-
 duced, that simple rest cannot  at once  allay;  his sleep is short,
 hurried, and 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 de-
clines.   Thus the quotidian makes  its assault in the  morning, the
tertian  at noon, and the quartan  in the afternoon : as though the 
Ml
ILKMATICA.
[CL. Ill—OR.  I.
diurnal revolution was somewhat regularly divided  between febrile
attack and  febrile cessation or truce.  It is possible, indeed, that
a fever of any kind may open its onset at any hour,  but this is so
contrary to the ordinary rule, that Dr. Fordyce affirms from his own
observation, that ten fevers commence in the day, to one at night.
  The species before us forms scarcely a case for medicine : since
nature, or that instinctive power which is ever operating to the ge-
neral welfare of the animal frame, will be usually found competent to
its object.  So that if any thing remedially is attempted, it should
be confined perhaps to a slight increase  of the peristaltic 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, Vater, and various writers
of credit, strongly recommended the same from personal experience
nearly a century ago.*
  Gamesters, after sitting up  all night, and being worked up to
madness by the chances and reverses of their  ruinous stakes, are
peculiarly subject to this species.  A  very cold and wet towel tied
round the temple 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.  Yet, the habit  itself appears
mischievous, however pleasant at the  time, as having a strong ten-
dency 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, lie admirabili Ipecacoanhx virtute, in curandis  febribus, &c.
Patav. 1754.—Vatur, Diss, de Ipecacoanhs virtute febrifuga, &c. Witeb. 1732.
\ 
L,E. I.—SP. II]      SANGUINEOUS FUNCTION.                61


                       SPECIES II.

                 EPHEMERA  ACUTA.

                   atcute  Bfarg iPefoer.

SEVERE RIGOR ; GREAT HEAT ; PULSE AT FIRST SMALL AND CONTRACT-
  ED, AFTERWARDS FULL  AND STRONG;  PERSPIRATION COPIOUS;
  GREAT LANGUOR.

In a few instances the accession is  slightly marked, and there is
little chilliness or rigor. The heat that succeeds, however, 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 the pain in the head is dull
and heavy.  The  high-coloured urine deposits a sediment with a
tinge of orange-peel.
  We cannot always trace the remote causes of this species; but
it is usually produced by some morbid affection of the stomach or
of the collatitious viscera.
  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
ihe consequence is that, in infirm habits, a considerable degree of
chill and  (Jebility 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 expecl 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. 
63
HJEMATICA.
[CL. HI.—OR. 1
 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  knoAvn mode of cure consists, in  the first
 place, in imitating  this process: in unloading the stomach of its
 mischievous freight by a powerful emetic, and the alvine canal of
 whatever portion of the heating and crapulous mass has passed into
 it, by a brisk cathartic.   The fever hereby excited will often  sub-
 side into a diurnal revolution; and no tendency to a return of the
 paroxysm be produced.
   If the species before us, however generated, do not subside within
 this period of time, or a few hours beyond it, the disease becomes a
 cauma, or inflammatory fever of the continued kind, and consequent-
 ly belongs to the genus enecia.
   There are, however, a  few exceptions to this rule: for Forestus
 gives a case in which  the paroxysm  led  to  fatal hectic:* and
 Borelli  gives another of equal singularity, in which it  kept true to
 a triennial revolution, returning punctually once every three years.t
                      SPECIES HI.

             EPHEMERA SUDATORIA.

                    Stoeatfufl=jFefoer.

1ENSE PAINS IN  THE NECK AND EXTREMITIES ; PALPITATION ; DYSP-
  NttA ; PULSE RAPID AND IRREGULAR; HEAT INTENSE; INTOLERABLE
  THIRST; DROWSINESS OR DELIRIUM ; EXCESSIVE SWEAT.

I have followed M. de Sauvages in introducing sweating-fever, the
ephemera maligna of Borsieri,| or Buserius as he is more common-
ly called, and the sudor Anglicus of most foreign writers, into the
present place.
  Dr. Caius, who practised at the time of its appearance at Shrews-
bury, and has written one of  the best accounts of it extant, calls it
" a contagious pestilential fever of one day "   " It  prevailed," says
he " with a mighty slaughter, and the description of it is as tremen-
• Lib. 1. Obs. 7.
f Cent. II. Obs. 100.
* Institut. Med. Pract, 3ro. 4 torn, Yen. 1782-5, 
GE. I.—SP. HI.]     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 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 su, porting 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 lo 1530: it then return-
ed to England, and was observed for the last time in 1551.
   It commenced its attack with a pain in the muscles of the neck,
shoulders, legs, or arms, through which a warm  aura seemed to
creep in many instances; and after  these symptoms, broke forth a
profuse sweat.  The internal organs grew  gradually hot, and at
length burning,  the pungent heat extending to the extremities, an
intolerable thirst, sickness, and jactitation  followed speedily, occa-
sionally with  diarrhoea,  and  always with extreme  prostration of
strength,  head-ache, delirium, or coma, and  a  wonderful  wasting
of the whole body.   The sweat  was tenacious; saburral, and  of an
offensive smell; the urine thick and pale; the pulse  quick,  often
irregular ; and the breathing laborious from the first.  The modes
of treatment  were often puerile, and offer nothing instructive.   A
good constitution and exposure to free air  seem to have been most
successful in promoting a cure.
   Dr. Caius asserts, that a thick noisome fog preceded the distem-
per, especially in Shropshire, and that a black cloud uniformly took
the lead, and moved from place to place; the pestilence in a regular
inarch following its direction.  There may be  some fancy  in  this :
but it is an unquestionable fact, that the most fatal pestilences of
ancient and modern times have been ushered in by stinking fogs or
mists, or some other intemperament of the atmosphere, of which the
reader will find various instances in the sequel of this work.
   The disease is generally,  however, supposed to have been pro-
duced by inclement harvests and vitiated grain, particularly wheat,
which is less hardy than other grains aud sooner infested with albi- 
 g4                        HiEMATICA.           [CL. III.—OR. I.

 go (mildew), ustilago (smut), and clavus (ergot or spur.)   And in
 proof that this last was the actual cause it is observed by Dr. Willan,
 that the contemporary inhabitants of Scotland and Wales, who fed
 on oaten or barley, instead of on wheaten bread, were not affected.
 Nevertheless, whatever was the primary cause, a peculiar miasm or
 contagion seems to have been generated by  the disease itself, which
 chiefly contributed to its spread and continuance.   For we are told
 concurrently  by all the  writers, that  Englishmen who withdrew
 from their 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. Friend adds, that, while English-
 men abroad were thus subject to the contagion, foreigners and even
 the  Scotch in England were rarely or never seized with it;* a fea-
 ture that has been copied by Dr. Armstrong in his  very  forcible
 description of the complaint, which is perhaps better adapted for
 poetry than for  sober prose.

          Some, sad at home, and, in the desert, some
          Abjured the fatal commerce of mankind;
          In vain : where'er they fled, the fates pursued.
          Others, with hopes more specious, cross'd the main,
          To seek protection in far distant skies,
          But none they found.  It seemed the general air,
          From pole to pole, from Atlas to the East,
          Was then at enmity with  English blood:
          For, but the race of England, all were safe
          In foreign climes; nor  did this fury taste
          The foreign blood which  England then contained.!

   Something may, perhaps, be set down to the score  of a national
diathesis;  but without examining very closely into the accuracy of
this wonderful part of  its history, we may at least indulge a hope
that  this peculiar, most virulent and fatal contagion has long since
worn itself out,  and become decomposed; though it  may  be still
only latent, and waiting for its  proper auxiliaries once more to show
itself in the field.t.
   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 this thesis " An febris putrida Picardii suete
dicta, sudorifera ?" has maintained Dr. Coste's opinion.
• Hist, of Physic. Vol. 11. p. 533.
f Art of preserving Health, B. III.
t Navier, Maladies Popularies, &c. 
GE. II.]
SANGUINEOUS FUNCTION.
* $5
                       GENUS  II.

                         ANETUS.

                Xutermtttcut jFcber.   ®%ut.

 PAROXYSM INTERMITTING,  AND RETURNING  DURING THE COURSE OF
   THE DISEASE: THE INTERMISSIONS GENERALLY PERFECT AND REGU-
   LAR.

 Under the preceding genus, the remote cause, whatever it consists
 in, lays a foundation for not 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 ihe disease lasts.   I say inmost
 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—miasmatepaludum ort<z—
 as though there were no other cause of their production, whence
 Dr. Young gives to intermittents and remittents the common name
 of paludal fever.
   The only ground then assumed for this union of intermittents, and
 remittents, is the supposition that the cause which generates them is
 single, common to the two, and never generates any other fever. Now,
 although  the febrile miasm, issuing from marsh-lands  is by far  the
 most common cause of intermittents, it is by no means the only cause;
 for we find intermittents, like all other species of fever,  produced
 from various sources ; existing in hot countries as well as in  cold,
 in high lands as well as in low lands, sporadically as well as epide-
 mically ; sometimes excited by sympathy, 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 pare
principii hie admittimus, licet neutiquam excitassent, 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.  I 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.  II.—I 
66  *
IUEMATICA.
[CL. 1U.—OR. I.
inhabitants escaped, when  in  the  year  1765 a most fatal and epi-
demic fever, originating unquestionably from the miasm of swampy
grounds, prevaded 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 affirms, that he has seen an intermittent communicated by in-
fection, meaning the miasm from human effluvium ; and where  ihe
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.}
   But one of the  most singular and convincing proofs, that the de-
composition of marsh-lands is not essential lo the production of inter-
mittent fever, is to be found in  the epidemic intermittent of 1780,' as
described by Sir George Baker, and which  we shall have occasion
to advert to more particularly hereafter ; for, during this,  the inter
mittent harassed very extensively the elevated parts of Lincolnshire,
while the inhabitants of  the neighbouring fens  were free  from its
ravages.§ And in like manner, the dry and healthy climate of Mi-
norca, is  sometimes attacked with  remittent or  intermittent fever,
while Sardinia, proverbial for its insalubrity and ferbile epidemics,
escapes.||                                                         •
  To unite remittents, therefore, with  intermittents, from an idea
of their having  a single and common origin,TS to depart from  the
clear line of symptoms into  a doubtful region of etiology.  If  inter-
mittents ought to  be separated (as unquestionably they ought) from
continued fevers,soought 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;  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 physiologists  in every part of nature ; and equally
calls for  discrimination in  zoology,  botany, and mineralogy : and
Dr. Parr  has  correctly observed, that, "if a specific  distinction can
* On Blood, Part II. ch. IV. p. 411.
f Act. Soc. Med. Hafn. torn  I. N. 10.
* He Putridine, Urbin, 1608.
§Med. Trans. Vol. III. Art.  xiii.
LCleghorn, Diseases of Minorca. 
GE. II.]
SANGUINEOUS FUNCTION.
67
 be established in any branch of natural  history,  it must be  in the
 separation of remittents from intermittents."  Vogel unites  remit-
 tent with continued fevers, to which Dr. Cullen, rightly enough, ob-
 jects; but the former has as much reason on  his side, as the latter
 has for uniting them with  intermittent.   Savages, Linneus,  Sagar,
 and most modern writers correctly distinguish each from the other.
   When an intermitting fever or ague is, by the operation of marsh-
 miasm, or any other cause, once  introduced  into the system, and
 has once discovered  its type, or given  an interval of a particular
 measure  between the close of the first and the  commencement of
 the second paroxysm, it continues true, as a general rule, not merely
 to the same measure or extent of interval, but to the length  and
 severity  of paroxysm, through the whole course of the disease; the
 character of the cold stage, determining that of the hot, and both
 together that  of the sweating stage :  and the paroxysm ceasing be-
 cause  it  has completed  its  career.  But the lirst interval, like the
 first paroxysm, which regulates the rest, is of a 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 :—
                                      QUOTIDIAN AGUE.
                                      TERTIAN AGUE.
                                      QUARTAN AGUE.
                                      IRREGULAR AGUE.
                                      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.
1.	ANETUS QUOTIDIANUS.
	
■ J.	
4.	■------ ERRATICUS.
5.	------- COMPLICATUS.
 
6£
H.KMAT1CA.
[CL. IH.—OR. I.
  Thirdly, the more durable the cold fit, the less durable the other
stages.
  Thus, the quotidian has a longer paroxysm and  a shorter inter-
val lhan  the tertian;  and the tertian a  longer paroxysm  and a
shorter interval than the quartan.   And thus again, while the quo-
tidian has the longest duration, it has the slightest cold stage; and
while the quartan has the shortest duration, it has the longest cold
stage.  It is also the most obstinate to cure.
  Each of these species, however, admit of considerable variations :
for sometimes we find the paroxysm protracted beyond its proper
period;  sometimes anticipating, and sometimes delaying its proper
period of return.   In other cases, we find each of these species
catenated  with  or giving rise to  foreign symptoms or other dis-
eases.  And we also meet with a peculiar variety of the quotidian
ague, in its being sometimes limited to  a particular part or organ,
in which case it is usually accompanied with very distressing pain.
  The most irregular of all the species is the  fourth, for this is
sometimes found to deviate from all the three rules I have just laid
down; but particularly in the  greater length of its interval, which
is sometimes double or even treble that of the quartan, whose in-
terval of seventy-two hours is the longest of the three more disci-
plined species ; it is hence found under the various forms of a five-
day, a six-day, a seven, eight, nine, and even a ten-day ague; and
sometimes is so extremely vague as to bear no proportion whatever
between  the violence of its paroxysm, the duration of its stages,
and the period of its return.
  The fifth species is  distinguished from the  rest by its peculiar
complexity, consisting of double tertians, triple tertians, unequal
tertians, duplicate tertians, together with  as many varieties of  the
quartan type; the nature and key of which will be more particularly
noticed under the species itself.
                        SPECIES  I.

              ANETUS QUOTIDIANUS.

                     (kuotfatau &jjuc.

INTERMISSION ABOUT EVERY TWENTY-FOUR HOURS : PAROXYSM  COM-
  MENCING 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
ot the complicated intermittent, which has  generally been denomi-
nated a double tertian, and with which it is often confounded. It is
distinguishable, however, to an attentive eye by the regularity of 
GE. n.—SP. 1.]     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
having an imperfect intermission, and in precipitating or procras-
tinating  every  subsequent paroxysm:  and hence, affords us the
following varieties:
       « Partialis.               Partial quotidian.
       /3 Comitatus.             Catenating quotidian.
       y Protractus.             Protracted quotidian.
       ^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 of the head, not unfrequently
 resembling cases of cephalaea, and  particularly that species of it,
 which is called hemicrania.
   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 and night.
• Class II. Febr. Intermit.  Quot. Spec. IV.
t Vol. II. Art. six. 
ro
HVEMATICA.
[CL. Ill —OR. I.
  The retarding quotidian,  which, like the last, has been particu-
larly noticed and  named by Dr. Fordyce,  forms a direct counter-
part to  the  anticipating;  the paroxysm delaying  its antecedent
period usually by about two hours,  and  continuing the same delay
at every recurrence ; so that here also the accession may be thrown
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, and several
species of odontia.
                       SPECIES II.

                ANETUS TERTIANUS.

                       ftcvtian &sue.

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. II.-SP. II.]
SANGUINEOUS FUNCTION.
n
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
paroxysms amounts to the space of fourteen days.  The tertian ex-
hibits occasionally the two following vaiieties :

      « Comitatus.                   Catenating tertian.
      P 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 foun.l 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  QJJARTANUS.

                       (kuartau ®qm.

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

 This, which is also the quartana of Celsus, is the tetartasus 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 former 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 oflonger  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 dulness 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 tumours,
and  especially of the spleen  and liver;  in  the  former of which
organs they are vulgarly called ague-cakes. 
T2
HJEMATICA.
[CL. III.—OR. 1/
  The quartan offers the following varieties :—•

    a Comitatgs.                   Catenating quartan.
    /8 Protractus.                   Protracted quartan.
    y Anticipans.                   Anticipating quartan.
    o 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.

                     Errcaulav &fltte.

INTERMISSION AND PAROXYSM POSSESSING LITTLE REGULARITY : THE
            FORMER 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 reader
may  turn to the volume of Nosology.
    «  Quintanus.                 Five-day ague.
    0  Sextanus.                  Six-day ague.
    y  Stptanus.                  Seven-day  ague.
    <J*  Octanus.                   Eight-day  ague.
    t  Nonanus.                  Nine-day ague.
     £  Decimanus.                Ten-day ague.
    jj  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 last variety is equally irregular as to the  violence of the  pa-
roxysm, the duration of its  stages, and the period  of its  return.
Several of Sauvage's species of hemicrania may be  properly re-
ferred to this place, and especially those, which, by some  writers,
have been denominated intermittentes larvatje, or disguised in-
termittents. 
GE. II.-SP. V.]     SANGUINEOUS FUNCTION.
                        SPECIES V.

              ANETUS  COiMPLlCATUS.

                     (gomjilfcatrt ®Lqm,

         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 minutely
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 alter-
nating distinctions.
  The following are the chief varieties :
« Tertianus duplex.
  Double tertian.
/3 Tertianus triplex.
  Triple tertian.
y Tertianus impar.
  Double unequal tertian.

S" Tertianus duplicatis.
  Duplicate tertian.
Quartanus duplex.
Double quartan.
£ Quartanus triplex.
  Triple quartan.

  Vol. II.—K
The paroxysms of the one tertian
   occurring  in the intermissions
   of the other:  and the two sets
   evincing a difference  of dura-
   tion or of violence.
A double tertian, taking place as
   above ; but one of the sets hav-
   ing regularly two paroxysms on
   the day of its return, and the
   other, one alone.
The one set evincing a more per-
   fect, the other a less perfect in-
   termission.
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 oc-
  curring in  the  intermissions of
   the other;  and evincing a dif-
  ference of  duration or of vio-
  lence : with an interval on the
   third day alone.
Consisting of a  single  quartan,
   with  regularly  returning  pa-
  roxysms ;  while  each  of  the 
                          ILEMAT1CA.            [CL.1U.-OK. I.

                                 intervening  days   is   marked
                                 with a slighter  or  separate  at-
                                 tack.
                               Consisting  of a  single  quartan;
                                 with two paroxysms on the re-
                                 gular day of attack ; the  inter-
                                 vals being of ordinary  duration.
                               Consisting of a single quartan with
                                 three paroxysms on the regular
                                 day of attack; the intervals being
                                 undisturbed, and of ordinary du-
                                 ration.

  Having thus distinctly noticed the several  species and  chief va-
rieties 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 symptoms,
as syncope, apoplexy, vehement spasms over the whole system, 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 carries off many chronic
and lurking disorders of other  kinds : Dr. Fordyce affirms that he has
seen it of considerable use in  curing or alleviating chronic rheuma-
tism, habitual indigestion,  cutaneous eruptions, protracted inflam-
mations, epilepsies, and hysteria.* And his assertion is corroborated
by other authorities.f
  The duration of intermittents is of great uncertainty. The vernal
agues generally disappear with  the advance of summer: the autum-
nal  are more  obstinate,  and especially the quartan.  Where they
have remained long, and have become habitual, even their removal
must be attempted with great caution; for when abruptly suppressed,
they have been known lo lay a foundation for a host of  other  mala-
dies, often of a more fatal description, as paralysis, various visceral
affections, and even sphacelus.
  Ludolf gives an instance of an eight-day  ague (anetus errattcus
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,| twelve,§ eighteen,|| twenty,!  twen-
* On Fever, Diss. n. p. 16.
f Salmuth, Cent. II. Obs. 14.—Ephem. Nat. Cur. Dec. III. Ann. III. Obs 30
* Eph. Nat. Cur. Dec. II  Ann. VIII. Obs. 45.
§ Avicenna, Fen. I. Lib. IV Tr. II. Cap. VI.
It Madai, Von Weekselfiebern  Sect. 144.
1 Eph. Nat. Cur. Dec. HI. Ann. IX. and X, Obs. 51.
jj Quartanus duplicalus.
  Duplicate quartan.
6 Quartanus triplicatus
  Triplicate quartan. 
 '.5E. II.—SP. V.]      SANGUINEOUS FUNCTION.                 75

 ty-four,* and thirty years,f and one instance of its 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, Swalvve, 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 cor-
 rectly 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,! 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. III. Cap. XIV. p. 291.—Pontanus, De. Nehus Co-
nel. L. VIII.
  f Binninger, Obs. Cent. v. N. 64.  Wierius Obs. p. 37.
  \ Gabelchover, Cent. VI. Obs. 75.
  $ Obs. Lib. VI. N. 36.
  U Cent. I. Obs. 94.
  1 Von Weekselfiebern, B. II. Cap. VI.
  *• Reil, Memorab. Clin. Vol II. Fasc. I. 
76
HiEMATICA.
[CL. UI.—OR. I.
 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 typhous form.  Great and sudden
 oppression of the head,anxiety, depression of spirits, a dry parched
 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
 syn ptoms 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 extraordinary want of power.   Half the  quantity of it which I
 used on that occasion was sufficient in this."
  In other words, idiosyncrasy 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 tendency
 to delirium.  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
obstinate resistance to this medkine.
  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. III. Art. XIII. 
 GE.II.—SP. V.]      SANGUINEOUS FUNCTION.               77

 Sir George Baker, " were in general no other than the common
 ague; but in the more inland countries 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 twiching of the extremities continued even in the inter-
 missions, 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 valleys
 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 wFich very few male servants,  especially the la-
 bourers in the open air, escaped^ But the distinguishing character
 of this fever was its obstinate  remittance 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 intensenessof 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. Trans. Loc. citat. 
78
HjEMATICA..
[CL. HI.—OR.l.
  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
  be-^t in vernal intermittents, and did not in general prove sufficient
,  for the autumal 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 primo
  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 powder, 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-
 lancls.  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,Micceed 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 preceeding : and when
 the shivering and  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. torn, I.  p. 193. " 
t.K. 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, inr
many cases of intermittents, been highly beneficial; diminishing the;
duration of the stage, and moderating its symptoms.  Dr. Trotter-
says, that he practised this plan with general advantage in an epi-
demic 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 baf-
fles on one occasion the remedy that has best  succeeded on another.
And  hence opium has often failed in other intermittents in every
from, but especially when  given in the cold fit.   And  owing to this  J |
diversity of effect, Dr. Lind thought it most useful in the hot fit;  ) 1
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 moderating the
heat, calmed the anxiety and  head-ache which are usual concomit-
ants, expedited  the sweating stage, made the paroxysms more regu-
lar, 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  physicians of reputation;
but it does not appear to be of superior efficacy, in any respect, to
the antimonial powder of  the London College.
  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      4
HJEMATICA.
[CL. III.—OR. r
And we may still further add to the ingredients of the medicine a
full dose of volatile  alkali with great advantage; for it is in  this
form, if "in any, that we can employ stimulants with  a certainty of
doing little mischief, and very nearly a  certainty  of considerable
benefit.  In the case of a quartan, in St. Thomas's Hospital, which
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 com-
plete cure to  the complaint.  They appear certainly to be  sedative
and diaphoretic, and it is said that the sweat they excite by a single
dose may continue for twenty-four hours without languor or debili-
ty.  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 auxiliary
means depend, in many instances, the accomplishment of the ob-
ject we have  in view, without which the most  urgent diaphoretic
exerts itself to no purpose.
  The most important season, nevertheless, for medical operation,
is in the intermission of the paroxysms :  since however successful
we may be in moderating the febrile attack, it is rarely that we can
depend upon  any plan which may then be adopted to  prevent a re-
currence 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 theonly 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 astrin-
gency, 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-
municated  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 de-
spise or think lightly of in the present day,  has never been altoge-
ther without its opponents; and there are many facts respeting 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
along 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.—L 
82
ILEMAT1CA.
[CL. HI.-OR. 1.
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 X.
in 1661, as a medicine perfectly innocuous and salutary : and a Sche-
dula Romana, drawn up under the sanction of the physician to his
holiness, pointed out in express terms the time and  proportion in
which the bark was to be taken. Unfortunately the time stated was
frigore 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
to 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, comprobatse 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,t 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
 prejudice, 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
* Pyretolog. p. 17.
t Medical Transactions, Vol. III. Art. 3UIJ,. 
•iC.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 ob-
 taining 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 one patient, who
 was attacked with  an obstinate  intermittent  fever in the month of
 February of 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 mace-
 rated 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 hark he
employed ;  and to allow of no intermixture, whether from fraud or
a view of increasing its virtue.
• Febrifugi Feruviani Vindiciarum Pars prior, p. 84.  Antwerp, 1659.
f Thorns Bartholini Hist, Anat. et Med. Ceqt. v. Hist. L. Hafnis, 1661. 
84
HiEMATICA.
[CL. 111.—OR. I.
  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 Ro-
mana.                                    L           J  11 ,u
  Under these regulations the bark seems  to have acquired all the
success to which it has at any time pretended : and modern practice
had 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—divi 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 twenty 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
neither 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 agyria Talbor.f   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 lo 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 atmo-
 sphere.   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.
   t 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 aUim 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 the 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 name 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 quantity of calx of anti-
mony, given every sixth  hour, is said  to have subdued, in the me-
tropolis, 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.
   ■ .1             -------------------------■--------              '  s'       , .  i . .
                  * Med. Transact. Vol. III. p. 165. 
S6
HJEMATICA.
[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 of
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 caryophyllatta (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  dependence is to be placed upon them ;
but when  given in combination, they almost rival the virtue of

           • Ephem. Nat. Cur.  Dec. HI. Ann. VII. VIII. Obs. 48. 
BE. H.—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 conjunc-
tion  with these, in order to give full  efficacy to  any medicine
employed as a febrifuge in intermittents ; and a principle that has
hitherto eluded all researoh.  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 than 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 nux vomica, and
ignatia amara, 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  Bourieuf from his own
practice strongly recommends the latter, and Paullini:f: 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 ten years of  age, who was killed  by taking
fifteen grains of it, divided into two doses, for an obstinate quartan.lf
   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 II. Ch. II. p. 72.
f Hist, de la Sosiete R. de Med. 1776. p. 340.
$ Cent. III. Obs. 45.
§ Act. Societ. Med, Hafn. torn. II.
Q Mat. Med. Part II. Chap. II. p. 76.
1 Philos. Corp. Hum. Morb. P. II. Cap. VHL 
88
HJiMATICA.
jCL. Ill—OR. 1.
 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 lo 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  acrid.  Yet  it
 is chiefly the bitter we  seem to  want in the present instance;  and
 if prussic acid rearly exists in others, and could be separated from the
 bitter principles 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 arsenic ;
 for  although various  oxydes of iron, mercury, zinc, and copper,
 have  been tried, and occasionally extolled, none of them have prov-
 ed 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.!  It 1S>  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 not appear 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.
  f Mat. Med. p. 412
  * Act. Med. Berol. Dec. I. Tom. III.
  § Gilibert, Adversar. Pract. Prim.—Slevogt, Pr. de permissions Prohib, et
probibitione Permisa. 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
so  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 formally 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
certain 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 discontiue its use.
           * Annal. de Hist. Nat. torn II. Madrid, 1800.
Vol. II.—M 
 90                       ILEMATICA.            [CL. III.—OR. I.

   In administering the bark, little needs to be added to the rule3
 laid down by Sydenham, and copied in the preceding  page.   Dr.
 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 to 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
 Bossieri 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 belabour-
 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.Rigand de l'Isle 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.f
• Clinical Experiments, 8vo  Edinb. 1780.
t Mem. de l'Institut. Royal de France, March, 24,1817. 
&E, III.—SP. I.]      SANGUINEOUS FUNCTION.               91



                      GENUS III.

                      EPANETUS.

                     Remittent iFefoev,

•symptoms strikingly exacerbating and remitting ; BUT WITHOUT
    intermission ; ONE paroxysm every twenty-four hours.

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

 1. EPANETUS MITIS.                MILD REMITTENT.
2.-------- MALIGNUS.            MALIGNANT REMITTENT.
3. -------- HECTICA.              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 in-
dividual cause of marsh-miasm : for it would be difficulty, 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.

                     JWfttr Remittent

fULSE REGULAR THOUGH FREQUENT ; DEBILITY  SLIGHT; REMISSION
      DISTINGUISHED 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 all seasons of the year, but more fre- 
92
IIJEMATICA.
[CL. HI.—OR. I.
 quently in the autumn;  the ordinary temperament of the season
 uniting with the patient's infirm state of health, and 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
 for 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 ;  for
 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 ceas-
 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 occassionally, 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. HI—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 salt3 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, re-.in 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 j
a fearful advance.   But with a course of brisk cathartics, in con-
junction with perfect  quiet, good  ventilation, and  light nutritive I
food, it  will  usually give way in a week or a fortnight.
                       SPECIES II.

               EPANETUS MALIGNUS.

                  fHalfsnant 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 sufficiently
marked by its own symptoms. 
y4                       HJEMATICA.            [CL. HI.—OR. I.
     » Autumnalis.                Autumnal Remittent.
     Q Flavus.                    Yellow Fever.
     y Aniens.                    Burning Remittent.
     S' Asthenicus.                Asthenic Remittent.

   The autumnal remittent is that which so fequently 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
 quotidian 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 nor 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.                $5

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 characterized.   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 where conges-
tion 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 whieh, 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, overflow  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, perharps 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 has its myste-
ries as well as every other branch of science; and let the man 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 
>ib
HEMATIC A.
|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 1 am persuaded, that the
 progress of nature is as certain and regular in these cases as in 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, yawnings, 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 whatever 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 increse 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 pro-
 duces 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 of 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. HI.—SP. If.]     SANGUINEOUS FUNCTION.               97

rather small; the bowels were relaxed, the motion 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 were colourless and watery,
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 watery
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 Damocratisin 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 tranquillyj
  Vol. II.—N 
98
ILEMAT1GA.
[( L. III.—OIJ. ».
 and columbo, in small doses of the powder,  was commenced the
 next morning, and persevered in.  The change of treatment, being
 thus found lo succeed, was adhered to, and the patient slowly but
 effectually -recovered.
   It is not often that the autumnal remittent is thus obstinate.  But
 whether there be sickness or not, an emetic should be administered,
 as one of the best means of determining towards the  skin.  And
 singular as the advice  may appear, it is rather to be recommended
 where there is Utile or no sickness  than where the sickness is in-
 cessant; for in this last case the stomach is often so extremely irri-
 table, 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 he sufficient for this purpose :  and
 hence Sioll allows of nothing beyond; for purging, says 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 dosesofantimonial 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
oroinaril)  constitute the best sedatives and refrigerants : and where
the debility is extreme, the stimulant plan should be had recourse
to, whicli  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. 
 t«E. HI.—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 ra-
 vages 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 \tjievre 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 essentially
 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
HAEMATIC A.
[CL. III.—Oil. 1
prove, at least to render it highly probable that they depend " 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
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 severity, 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 typhus, and sometimes
a synochous, or, in other words, begins with the first and runs rapidly
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. Mosely, who, from
its resemblance to the causus of Hippocrates, denominates it ende-
mial 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. HI.—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 ;  skin 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 thrist, 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, accompa-
nied 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 violently
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,* particularly suffer in the malignant au-
tumnal remittent of our own country ; more especially the stomach
• Epanetus malignus, Vol. p. 139. 
102
HJEMATICA.
[CL. III.—OR. I.
and the liver.   Hence the intense heat and anxiety about the prse-
cordia, the saffron dye of the urine, the yellow tint of the skin, and
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 rushes
forward at  once to  its acme,  constituting the second stage  of Dr.
Mosely.  The patient is sometimes cut off in four-and-twenty hours ;
and, from the  violence so suddenly committed on the liver, its pro-
per function is instantaneously 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 lividity
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 skin,  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. 
GE.1II.—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 at 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 at 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 almost
all the different kinds of fever that  occur to us, are capable of issu-
ing from a common source or miasm, merely modified by contingen ■
cies :  for in Antigua they all occurred in different individuals.  The
disease sometimes commenced as an intermittent or remittent, antr
sometimes in  a continued type; it sometimes ceased in four or five
days,  which was its usual course, and sometimes terminated \x\ an
intermittent.  The head was in some cases chiefly affected; in others
the stomach,  liver, or some other organ:  sometimes the patient
died without hiccough or black vomit, though he r.arely 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-Chirwg. Trans. Vol. IX. p. 92. 
104
H-OIATICA.
[CL. III.—OK. 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
 colour; 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 ap-
pearance 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. II. p. 47. 
CL. IH.—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 affected only across the
streets.  The more narrow  the  steeets,  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 to
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 inflam-
matory diathesis  should continue  manifest.  " I 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 I supposed to be the effect of
   Vol. II.—O 
106
ILEMATICA.
[CL. 111.—OR. I.
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 fullness or  tension."  And he affirms, that both
petechia and vibices  disappeared in various  cases after bleeding.
This plan he often pursued through  the fifth  and even the seventh
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 underthe 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 wofully 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 \o  be
pursued.  It may  be, that eight-and-forty, or even four-and-twenfy
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 the inflammatory diathesis by debilitating and
relaxing the living fibre or solidum vivum, rather than by diminish-
ing the motes 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, 
CL. HI.—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
 in 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, tiiat  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, siomach,
 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  lo 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 the subject,
in observing, that while  the Bulam fever, or the disease in its most
* Vol. HI. Letter xii. p. 134. 
108
HiEMATICA.
[CL. IH.—OH. I
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 for 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 favour-
able result under any mode of treatment, it must also be re-
membered that eveky  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, be-
cause of the  fatigue  endured under the  latter.  Bark was then  in-
stantly 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.
   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 " iebris 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 tlie prsecordia, 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 lime; 
GE. III.—SP. H.]    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 lhan 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 formerly
ascribed,  are long exposure  to the heat of the sun, great fatigue
from 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, febrile
miasm issuing from this source, may, as I have already suggested,
produce  a caumatic or  inflammatory, as  well as  a synochous  or
typhous tendency, in constitutions predisposed to  this character of
fever: for the causus is in  fact, whatever be its cause,  a vehement
inflammatory 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
applications 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 applica-
tion of cold  air as well as of cold water; and gives an instance of a
rapid cure in one who in a state of delirium exposed himself naked
to  the cold of the atmosphere out of  doors.f  And on this account
Schaffer  advices that the patient, in any  acute fever accompanied
with dry  burning heat,  should be carried from his chamber, on a
matlras, and thoroughly ventilated abroad.:}:
  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 I  have already endeavour-
ed to lay down as far as  we are acquainted with them.§  This mo-
* nig/ n*8»v p. 518,1. 48. 51. p. 419. 1. 37.
f Observations sur la Guerison de plusieurs Maladies.
* Versuche. I. p. 164.                          § Vol. II. p. 53. 
110
HjEMATICA.
[CL. HI—OR. I.
 dification of the disease, therefore, is best distinguished by the name
 Of ASTHENIC REMITTENT.
   The epidemics of this kind that arc 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 mois-
 ture, 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 dispirited armies, maintaining their ground with diffi-
 culty 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, consti-
 tuting the disease to which  M. de Sauvages has given the name of
 tritseophya 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 praecoidia; 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
 occasional 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. Pinkard has very  strikingly noticed  in  his
 own  case.   The  symptoms varied considerably from  this period,
 and he  had still many dangers to contend  with.  He recovered, 
GE.UI.—Sl'.H.]      SANGUINEOUS FUNCTION.               HI

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  petechiae ; evidently from
debility of the capillaries: a fact that has often occurred even in
the slighter attacks ol  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  scubiei 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
Ihe 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  " pu-
aniei vapeurs de  la mer,"  as Sir John expresses himself, " qui  faient
bondir la 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
HJEMATICA.
[CL. HI.—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
opened 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 for
such purpose nothing bids fairer,  or has in fact been found  more
successful, than the use of warm diaphoretics  with opium.   Cold
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  with very
great advantage.*
                       SPECIES III.


               EPANETUS  HECTICA.

                      Wlcrtfc iPeber.

PULSE WEAK : STAGES OF  CHILLINESS, HEAT AND SWEAT  VARIOUSLY
  INTERMIXED, AND SOMETIMES SINGLE J THE  COLD STAGE EXHAUST-
  ING 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.
Linneus, Crichton, and Parr,  into the present division, or that  of
remitting and exacerbating fevers: Boerhaave regards it as of a
mixed nature, a cuntinued intermittent. " Febris hectica," says he,
" est referenda ad febres continuatas intermittentes."  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
symptomatic, I could not  consent to admit it  into the list of idiopa-
thic 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 qusp Wratislaviam, anno.  1737, afflixit. Vide Act. Nat.
Curios. Tom. X. 
GE. Ill—SP. Ill]     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 effectually, 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
disease.
  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
good, the local irritation  is so considerable that it cannot muster up
a sufficiency of remedial energy to  subdue it;  and  hence, while
sympathising 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 for 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 the heart, 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 author's Nosology, " to idiopathic hec-
            • On Blood, Part II. Chap. IX. Sect. I.
Vol.  II.—P 
114
HiEMATICA.
[CL. III.—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 fea-
tures 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
disposition.   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.!   And it  is hence possible that
hectic fever  may occasionally  spring, like other remittents, from
febrile  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 func-
tion, however much it was decreased before.  The particular symp-
toms are debility; a small, quick, and sharp pulse ; the blood forsak-
ing 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
• Prxlect. p. 19.
t Arnold. Diss, de Hectica stomachia, 1743, 
GE. III.—SP. HI.]    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 lhat
 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  times 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 con-
 tinuance 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 one hundred, or a hundred and twenty strokes in a
 minute, there will be  real ground of 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
combat, 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. IT. Art. I. p. 6 
  116                     HiEMATlCA.            [CI.. IH.-OR. I.

  of these the vegetable will usually be found preferable to the mine-
  ral, since, on account of their corrosive property, the latter 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 answer 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 accelarate 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 Everard 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 dependent
 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  IX.

                         ENECIA.

                     (EtwtuittCu' iPetox.

ONE SERIES OF INCREASE AND DECREASE :  WITH A TENDENCY TO EX
  ACERBATION AND REMISSION, FOR THE MOST PART APPEARING TWICE
  EVERY TWENY-FOUtt 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  iwo
tides or fluxes  within the twenty-four hours, the one occurs in the
morning, and the other in the evening.  The last is always the most
distinct; 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 further 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
lo this habit he ascribes  the existence  of  an evening increase of
continued fever.
  The genus,  thus defined and characterized, includes  the three
following species:—

  1. ENECIA CAUMA.                 INFLAMMATORY FEVER.
  2. ------- TYPHUS.               THPHOUS 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 symp-
toms, 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 fre-
quent to enable us  to lay hold of  it in assigning their specific  cha-
racter.
                        SPECIES I.

                   ENECIA CAUMA.

                  Xnflammatorg Jfetocr.

HEAT GREATLY INCREASED ; PULSE QUICK, HARD, AND STRONG; URIW.
            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
Lommius ;  sanguineous continued fever, which is that of Hoffman : 
118
IIJEMAT1CA.
[CL. HI.—OU. J
and synocha, which is that of Sauvages, Linneus,  Cullen, and most
writers of the  present day.   Of these, synocha, 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 differ-
ent senses  by  different writers, and  approaches so nearly to syno-
chus, used as extensively Dy most of the same writers, as to create
a perpetual confusion in the minds of young students; and the more
so, as the disease before us is expressly denominated synochus by
Vogel, whilst  most writers employ this term to import a different
species of fever.   On all which accounts I  have judged it right to
exchange synocha for cauma, a term already employed for the same
purpose  by Dr. Young, and  which,  derived from kxi^u, " 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-
sia,  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 the term " local in-
flammations."
   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,t 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 human 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, 8tc. 8yo. London. 1779.
t Vol. II.'p. 41. 
GE. IV.—SP. I.]     SANGUINEOUS FUNCTION.
ny
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 basin, 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 parti-
cles 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
regular; the nausea subsides, and the  patient will take and retain
whatever is  offered  to  him of simple nutriment or medicine :  the
thirst is less violent, but the  tongue is deeply furred, and the lips
are parched.
  The disease is not often dangerous; and about the eleventh day
gradually subsides,  or yields  to some critical discharge, which is
usually that  of a free and alleviating perspiration. The pulse soon
sinks to eighty, and the chief symptom is weakness.
  During the course of the fever,  every organ suffers from its mor- 
120
HJEMATICA.
LCL. HI.—OU. I.
bid and increasing impetus; but they do not suffer alike: for in
some parts there is, occasionally, a greater spasticity or tetanic re-
sistance in the blood-vessels, to the flow of the circulating fluid than
in others, whence  that acute pain which is often complained of in
the head or the side;  in the latter case, sometimes amounting to
pleuralgia. And, not unfrequently, the vessels of one part will give
way more readily thon 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 he 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 be sometimes produced from febrile miasm, though it is
commonly derived  from other sources.   Of these the stimulus of
violent passions is,  perhaps, one of the most common; and especial-
ly upon  a vigorous and plethoric habit; which is the  usual  tempera-
ment  in which inflammatory fever makes its appearance.  Undue
muscular exercise, heating foods, or excesses of any kind in  the
same habit,  are also frequent causes;  while another may be found
in the suppression  of any accustomed discharge, as that of  men-
struation, epistaxis, or periodical blood-letting.  Suddenly suppres-
sed perspiration is, in like manner, a frequent, perhaps  the most
frequent cause of  any ; especially when the blood is very hot, and
the change is effected by exposure to a temperature of great cold,
applied externally or  internally,  as that of a current of cold air, a
large draught of cold water, or plunging into a river.
   Some writers, as Sennert and Crichton, have supposed inflam-
matory fever to be occasionally produced by an absorption of bile
into the blood-vessels under the excitement of a tropical sun, or of
a torrid summer in milder regions ; and they suppose that the bile
is, in this case, possessed of a more than ordinary degree of acri-
mony, and that the symptoms are varied by a more pungent heat
and more intolerable thirst,  with a more scanty secretion of urine,
preternaturally acrid and high-coloured.
  That bile  of this description is often forced back into the system
under the circumstances here supposed, is unquestionable ; as it is
also that inflammatory fever is a frequent accompaniment of this
morbid change.  But notwithstanding the above authorities, such
fever seems less attributable  to the reflux of bile into  the  blood,
than to the insolation or solar excitement; which, by unduly stimu-
lating the liver, has been Ihe 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. IV.—SP. I.]     SANGUINEOUS FUNCTION.
1£1
 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 which seventy-two were
 discharged  during a fit of vomiting and sneezing, from which time
 the patient  began  to recover.
   These vermicles were most probably  the larves of some species
 of the oestrus or gad-fly, which had crept up into the frontal sinus,
 after being hatched in the nostrils, in which the parent insect had
 deposited her minute  eggs.  This is a very common affection in
 grazing quadrupeds, and especially in sheep, which are often pecu-
 liarly tormented, and sometimes driven almost mad by the  violence
 of the irritation.
   Stoll gives  a case in which the brain, on examination after death,
 was found deluged with serum diluvium serosum.* But such an ap-
 pearance is rather to be regarded  as  an effect than a cause of the
 disease; as an instance of cephalitis profunda, in consequence of
 the brain having suffered more than  any other organ from the in-
 flammatory impetus.
   Hence the  following varieties are  noticeable under the present
 species:
 «  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.
 *  Biliosum.                     Accompanied with an excessive
   Bilious inflammatory fever.         secretion of bile absorbed into
                                    the sanguineous system.
 y  Pleuriticum.                   Accompanied  with a  violent
   Pleuritic inflammatory fever.       stitch or pain in the  side.
 £  Cephalalgicum.                Accompanied with acute pain
   Cephalalgic inflammatory fever.   in the head.
   As an inflammatory diathesis constitutes the essence of this fever,
 the cure must depend altogether upon a reduction of the vascular,
 and especially of the arterial entony:  always bearing  in mind the
 possibility that the disease may suddenly lose its inflammatory cha-
 racter, and rapidly pass into that of a typhus.   Regulated by this
 view, we should generally commence with  bleeding, and  cooling
 purgaiives.  There are a few cases, indeed, in which bleeding may
 be dispensed with, as when the habit is by no means plethoric, and
 the pulse obstructed rather than hard; but these are cases that rare-
ly occur.  Diaphoretics, or relaxants,  as they are denominated by

                      * Mat. Med. III. p. 294.
  Vol. II.—Q 
122
HJEMATICA.
[CL. HI.—OR. I-
Dr. Fordyce, may then be employed with advantage.  Of these the
tartarized antimony, the antimonial powder, or James's powder, are
chiefly to be relied upon ;  and may be  given  alpne, or,  which is
often better, in saline draughts; and particularly  those formed  of
the acetate of ammonia.   And it may not be amiss to observe here,
that the acetate of ammonia is sometimes prepared in the form  of
crystals,  and sits  more easily on the stomach in this than in any
other shape.  When given  as a liquid, it is of importance that the
solution should retain the carbonic acid gass 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 gass which it contains ;
so that in a pint of the solution of the acetate of ammonia,  com-
prising four drachms of the latter, there will be extricated, if made
in the manner  here recommended, little less than a  hundred and
sixty cubic inches of air.
  As  the stomach is for the most part but little affected,  emetics,
if used at all, can  only be employed for the purpose of determining
to the surface; but as we can  do  this by the antimonial and  other
diaphoretics, just referred to, as also by diluent drinks, it  is hardly
worth while to irritate the stomach in order to accomplish  the same
purpose.  Perfect rest of body and mind, a reclined position,  and a
light liquid diet, destitute of all stimulants, are also indispensable
toward recovery.   The  air should by all means be kept  pure, by
being constantly renewed, though without a sensible current, the
temperature cool, and the clothing light and  as often changed  as
may be necessary to maintain cleanliness.
  After all, however, it is not often that examples of pure inflam-
matory fever are to be met  with in the present day; and it is con-
tended by very high authorities, and seems to be established by the
medical records of earlier times compared with those of  our own,
that it is a disease far less common now  than it was formerly; and
that it is seldom, to adopt the words of Mr. J. Hunter, " that phy-
sicians are  obliged to have recourse  to the lancet, at least to that
excess which is described by authors in former times.  They are,
now, more obliged,"  continues the same writer," to have  recourse
to cordials  than evacuations;  and, indeed, the diseases called the
putrid fever and putrid sore throat are but of late date.  I remem-
ber when the last was called FotherghTs 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, he. Part II. p. 227. 
 GE. IV. SP. I.]      SANGUINEOUS FUNCTION.                123

   It is not easy to account for this change in the national tempera-
 ment.  It is common, indeed to ascribe it to an alteration in our
 mode of life,  which is asserted to be much fuller than that of our
 forefathers.  " We may be said," says Mr. Hunter, " to live above
 par.  At the full stretch of living, therefore, when disease attacks
 us, our  powers cannot be  excited further, and we sink  so as to re-
 quire being supported and kept up to that mode of life to which we
 have been accustomed."
   If this be a correct view of the times in Mr. Hunter's day, they
 have greatly altered and improved within less than half a century:
 for there has never been a  period, since wines and fermented liquors
 have been introduced among us, so temperate  and sober as the
 present.   Drunkenness, which was formerly common in  our streets,
 is now rarely met with; suppers are almost  entirely relinquished;
 and instead of its being disgraceful, as was the case in  ' the olden
 time,' for the master of the house to let his guests leave him either
 sad or sober, nothing is now  so disgraceful  as intoxication.   It is
 true, we are got back again to a very free use of the  lancet in many
 instances; which would  seem  to show that we had completed a
 revolution in our general temperament,  as well as our general
 temperance; but it is not a little singular, that while the lancet is
 still used with comparative  caution  in inflammatory  fever,  it is
chiefly employed  and often unsparingly in typhus, or putrid fever.
And hence, there  is more reason, I fear, for suspecting a revolution
in the professional fashion than in national temperament; and that
the bold and the timid plans have been alternately introduced,  and
alternately dropped, not so much from  any radical  change in the
constitution, as from their being found to fail, because employed as
popular means, or under the influence of some favourite hypothesis
on all occasions, without a due degree of clinical discrimination, or
attention to the habits or symptoms of individuals  at their bed-side.
                        SPECIES II.

                         TYPHUS.

                       Egpnus iPefeer.

PULSE SMALL,  WEAK,  AND UNEQUAL;  USUALLY FREQUENT; HEAT
  NEARLY NATURAL;  GREAT SENSORIAL DEBILITY, AND DISTURBANCE
  OF THE MENTAL POWERS.

The term is derived from Hippocrates, who uses it, however, in a
sense not exactly  parallel with its  application in modern times.
It is, nevertheless, admirably expressive of the general nature of
the fever to which it was applied at first, and which it designates at 
124
HJEMAT1CA.
[CL. HI.—OR. 1-
present; which burns, not with open violence as the cauma, but with
a sort of concealed and smothered  flame;—for the Greek term
Tv<pa> signifies " to smoulder," or " to burn and smoke without vent."
  Any of the ordinary causes of fever may be a cause of typhus, for
the typhoid form is often  dependent upon the  character of %the
constitution into which it is received, as evincing a great deficiency
of sensorial power: and hence cold, mental agitation, excess of
muscular labour, and even intemperance, which in 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 miasm, issuing
from the decomposition of human effluvium, under the influence of
the ordinary auxiliaries of a close and stagnant  atmosphere; still
farther corrupted by a load of foreign  exhalations from dirt or filth
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. II. CI. 1U. Ord. I. p. 49. 
GE. IV.—SP. II.]    SANGUINEOUS FUNCTION.
125
formation.  In many cases, indeed, all the secretions are alike con-
taminated ;  and, hence, febrile miasm is often  absorbed, in dissec-
tion, 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 energy, is less
volatile than that of marsh-lands or dead organized matter, its in-
fectious  power is confined to a much more limited atmosphere than
that of fevers originating from this latter source.  And, on this ac-
count, 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 recall the reader's recollection to ano-
ther remark that has also formerly been made, that in a pure at-
mosphere, 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 ag-
gravate diseases of  every kind. And hence, again, we have an obvi-
ous 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. Hay-
garth has observed, in  the patient's own chamber, if large,  airy,
and kept clean.
   It is also of great importance to  know that  typhus miasm, like
the specific miasms of exanthems, does not render clean clothes of
any kind contagious;  or, in  other  words, does not  adhere  to or
harbour in them.   When, however, they are  not clean, they may
unquestionably be rendered contagious; and, hence, it is probable
that the animal filth with  which  they are  impregnated, while it is
• Vol, II. CI. I. Ord. I. Sect. 9. p. 53. 
126
IUEMATICA.
[CL. III.—OR. I.
 a source of additional matter, becomes  a fomes of that already
 formed, and separated from the patient's body.
   A susceptibility, however, to diseases of every kind varies very
 considerably in different individuals:  and  hence we find that many
 persons upon an equal exposure to typhus contagion with others,
 receive  it far  less readily, and in some cases seem  to be almost
 favoured with a natural immunity.  As we have already remarked
 that  a particular  state of body gives  a peculiar tendency both to
 generate and receive  typhus, we can easily conceive that where
 the body is in an opposite state it must be  much less susceptible of
 its influence;  and  we are thus put in possession of  a general cause
 of escape. But there seems to be something beyond this, dependent
 indeed, not  upon the incidents of more vigorous health or higher
 animal spirits,  but upon the  nature of the  idiosyncrasy itself.
   Dr. Haygarth has endeavoured to determine,from very ingenious
 and  plausible data,  the  average proportion of those  who in this
 manner  remain exempt from contagion, while spreading on every
 side around them.  And he limits the immunity to one in twenty-
 three: for he tells us, that when one hundred and eighty-eight men,
 women and  children, were exposed fully to the typhous contagion
 for days and nights together, in small, close, and dirty rooms, all of
 them, except eight, were infected with this fever.*   And he has
 farther endeavoured to  show,  that the  miasmic  poison, when
 received into the body,  continues in a latent state for seven days
 from  the time of  exposure to the contagion, before  the fever
 commences, and may continue in the  same state  for seventy-two
 days, beyond which we have no instance of  its producing any effect.
 And this deduction is in pretty close unison with the experience of
 Dr. Bancroft,! who in ninety-nine cases of orderlies and nurses that
 attended the English army on its arrival at Plymouth from Corunna,
 in 1809, observed that they were rarely attacked with fever earlier
 than the thirteenth, and in no instance later than  the  sixty-eighth
 day.
  Man, however, is so much  the creature of habit, that his constitu-
 tion is in a thousand instances brought 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-
stituton—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. 
GE. 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 are other persons again,  as  Sir George Pringle has well
observed, whose constitutions forming a middle line between those
who readily receive, and who powerfully resist the contagious aura,
are affected only in a modified  degree.  They bend to the assault,
but are not cut down by it.  They become feeble and irritable; the
sleep is disturbed;  the  tongue  white in ihe 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 typhous character, and some-
times specific typhus itself.*  And, as in this case, the miasm is apt
to spread  more widely,  typhus has by many writers been said to be
occasionally epidemic.  When, however,  the disease issues  from
this  source, it is far more generally in temperatures too low than too
high and  heated;  since, as already observed, cold, and  especially
cold and  moisture, have a peculiar tendency  to depress the living
power: and hence this disease is said to be almost stationary at
Carlscrone, or at least to have lingered there  for four or five years
on some occasions.!
   Typhus, therefore, originating from different causes, and all these
causes modified in their action by collateral circumstances, may readi-
ly be supposed to be accompanid with very different symptoms,
and to appear under very different degrees of severity.  The chief
varieties,  however, are the two  following :—

       « Mitior.                  Nervous fever.
       C Gravior.                 Putrid fever.

   The first variety, or mild typhus, was called by Dr. Huxharn/eAr/s
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 praecor-
  • Epanetus malignus asthenicus, Vol. II. p. 111.
  f Foxe Neuen Schwed. Abhandl. Band. VIII.
  $ Manningham: on "The Symptoms, Nature, and Cure of the Febricula,
commonly called the Nervous or Hysterical Fever."  Lond. 1776. 
128
H-EMATICA.
[CL. III.—OR. I.
 dia; nausea; sighing; despondency; coma,  or quiet delirium;
 whey-like urine.
   •When the disease appears sporadically, it is usually under this
 form.  There is nothing  alarming to the  patient's friends  on its
 accession.  The first symptoms are slight, the tongue exhibits little
 change, and the pulse is only a little quickened, and somewhat smal-
 ler than usual:  at the same lime, 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 sunk.   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,f
 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 march, and the marked and
• Rat. Med. HI. p. 79.
t Med. Trans. Vol. V. Art. XXII. 
  GE. FV>-SP. U.]      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
  situations.
   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 five,
  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 full,
 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-
 jected.
   The balance of the sanguiferous system is generally much disturb-
 ed, 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.  These
 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
 occur 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 finger 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 with
 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 haemorrhage from one or more
 organs, soon afterwards usher in death; the period of which is ex-
 tremely 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.—R 
ia0                      IlJEMATlCA.             LCL. lHr-°ni

petechiae, or as it should rather be written petecehiae, this variety
has been very generally treated of on the continent under the name
of febris petechialis, or petechizans ; sometimes, as by Follini* and
Matarasius,t under that of febris peticularis ; sometimes, as by Ja-
cobi and Morelli,! it has been called febris purpurata ; while by  a
Castro it is termed febris punctularis ;§ and by De Cermona, febris
cum punctulis.\\  By the Spaniards, it was hence vulgarly denomi-
nated tavardillo or tabardillo, from tavardo, a spotted cloak former-
ly in common use.  These 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 haemorrhagica 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-
cient 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.
\ De Febribus peticularibus malignis, contagiosis, &c. Mezarini, 1722. 8vo.
i De Febra purpurata epidemica.  Lion. 1641. 8vo.
§ Febris maligna punctularis aphorismisdelineata.  Tub. 1693.
\ Tract, de Peste et Febribus cum punctulis.  Sevilla 1581. 8vo. 
 GE. IV.—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
 fever ;  and in a few days more the whole family perhaps were at-
 tacked one after another, with the same distemper.   I have oftener
 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 faithful
 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  per-
 son, which are equally sure to follow.  And we may hence see why
 typhus 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 more 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 seethe 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, I may add, superintended by the
 active 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 family we have
 just beheld into fifties or  hundreds; ever remembering,  that the
 virulence of the febrile poison  increases in power, not in 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  inca-
 pable 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 a 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. P. Phvsician to the Army. See Med. Trans. Vol. HI. Art.
XXII. 
132
HJEMATICA.
[CL. HI.—OR. 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 like a 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 support-
ing the vital power, and restoring its lost energy.
  The peculiar properties by which typhus miasm is distinguished
from miasm 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 propenies may in some degree be dependent
upon the first; but it does not appear to be entirely so;  since wc
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
rosalia or  scarlet-fever, small pox and plague, are also capable of
tainiing 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 stale; 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
body;f by washing the bandages employed  in typhus gangrene,!
and, in innumerable instances, by the communication of  a minute
drop of any of the fluids  of the  dead  body to  a punctured finger
during 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 results 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. VII. VIII. 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 be an
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 further 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 prohi-
bition.
  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, into
the sanguineous system.  Hence the fever will be aggravated from
local irritation, and the affected organ will  be in danger of inflam-
mation 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
HJEMATICA.
[CL. HI.—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 ihere 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  typhus 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 revellen.t; 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 lone 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 precuisive and generative of the sensorial debility, while
* Practical Illustrations of Typhus, &c. 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, is
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 the patholo-
gists 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
preventing 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
equal 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 anew
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-
tions, which 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 common
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 many

  • Appendix to his  Remarks on the Constitution  ef the Medieal  Depart
ment, &c. 
  156                      HJEMATICA.             [CL. Ill—OR. I.

  instances,  have cut short the attack of typhus,  and thus proved a
  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
  satisfactory explanation.
   But I have already observed  that  the  theory is of little import-
  ance provided  the practice has justified itself by the event.   How
  then stands the sum of general  opinion  upon  this subject ? The
  practice is, by no means, new, though ordinarily supposed to be of
  recent origin:  for it  has alternately lived and died  away, been re-
 vived and again sunk into disrepute, for  considerably upwards of
 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: of which any one may
 convince himself who will turn to the books  referred to in proof of
 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 support-
 ers of ihe 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-
 turies is against him.  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

  • Bernardi Caxanes, De Uatione mittendi sanguinem in Febribus putridis,
Barcelon. 1592.
  Sylvaticus,  De secanda in putridis Febribus, vena  quam Salvatellam dicunt,
1583.
  Thurini, An in omni Febre putridS. competat phlebotomia, Rem. 1545.
  Nigiisoli, Progymnasma de vena in Febre maligna secanda, and superior*!
an inferiori.  C.uastalla, 1665.
  Suavalla, Ergo maligns febri venxsectio,  Paris, 1694.
  De Biichner, Diss, de Venesectione in febris acutis malignis, Halle, 1757.
  Gilchrist, Edin. Med. Essays, Vol. IV.  Art. XIII. 
  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 symptoms 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," continues he, "I ima-
  gine 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 well worthy of attention, as containing the free 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 lo 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 afterwards,  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. Essavs, Vol. IV p. 281.
   Vol. II.—S 
 138                      1LEMATICA.            [CL. 111.—OR. 1.

 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 I cannot avoid quoting it. After
 the famous 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,  proceeded 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. Hennen,t " 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 type, and  pressed on our consideration the propriety of
blood-letting, was, that the spontaneous hemorrhages which for-
 merly sunk  the patient's strength were now accompanied with ob-
 vious relief." And he proceeds to state that from  this time the prac-
 tice 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 exception, but
 not to mistake the exceptions for the rule.  " The art of physic,"
* Principles of Military Surgery, p. 19.
fid. 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 especially
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.f Among the latter 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 espe-
cially  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 ethumidis 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,f and Dr. Cyrillo's paper on the   subject in the philoso-
phical 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 exter-
nally and internally.ft  And to prove how  torpid to common im-
  * Med. Trans. III. 417.
  | Ileg/ Nous-w, II. p. 484. 50.
  $ Medici ax, Lib. ID. Sect. xx.
  § Mursina iiber Ruhr und Faulfieber.  Loeffler, Beytrage, &c.
  B Eph. Nat. Cur. Dec. III. Ann. III. 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.
  ft Cent. 1. Obs. 66.                       ..,.,,.,     ...
  See also Nehemias (Abrah.) De tempore aqua: frigid* in febribus ardentibus
ad satietatem  exhibenda:. 8vo. Venet. 1591. 
140
1LEMAT1CA.
[CL. HI.—OR. I.
 pressions the body is under nervous fevers generally, and how little
 disposed to be injured by such  applications  it is only necessary to
 advert to the case of a patient at Lucca, given by Dr. J. Benevuti,
 in another  part of  the  Transactions  just referred to.   On  the
 ninth  and tenth day from the incursion of a malignant fever, he was
 thought to  be in great danger.  On the eleventh, he expressed 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  further 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,
 appears  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 ;f 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 recommendations of Dr. Currieof
 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 x.*rctx.\v<rii 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
 patL-nt 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 too  violent and exhausting to  be
 employed after the first three or four days of attack ; beyond which
Planchon.Journ.de Med torn. xxx. p. 127. Lamarque, id. torn. LXVI. 460.

* Phil. Trans. VIII. 1768. '
j De Gelidi Potus abusu. 4to. Cesen. 
 GE. IV.—SP. II.]     SANGUINEOUS FUNCTION.                141

 it will generally be most useful  to  restrain ourselves to epithems
 about or all over the head, the hair being removed for this purpose,
 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 succeeds,
 the usual salutary effects are, a considerable diminution in the num-
 ber 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,  spunging 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 physiologist
 has  hitherto satisfactorily explained by what means these  effects
 are produced.   And I throw out the hint, that so instructing a  sub-
ject 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  dependence, 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. II. ch. iii. Phil. Trans. 1774, p. 432. 
142
ILEMATICA.
[CL. III.—OK. I
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, li'*e 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 differ-
ent powers; as with large doses of nitre,  which Haenel seems to
have found highly serviceable ;t or nitre and calomel, which was at
one time a favourite practice in Germany;! 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 valuable medi-
cine on the present occasion, and cannot well be given too 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 oftener.§
It was given with equal freedom by  Stoll,|| Salle,!  and Chambon
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.
  f Epist. ad Haller, II.
  $ Abhandlung von der Wirkungen des Camphors und Calomels in anhalten-
den Fiebern.
  § Abhandlungen, &c.
  !| Rat. Med. III. 89.
  f N. Beitrage, I. 171.
  ** Traite" de la fievre maligne. 
 GE. IV.—SP. H.]      SANGUINEOUS FUNCTION.               145

 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 at one 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 may be
 safely persevered in, or even increased if necessary.
  Under the influence of Dr. Brown's name, both MJne'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 belive: for Borelli,  Chamdon de
 Montaux and Reidlin gave it quite as largely, and at least with as
much success.  Borelli prescribed it in injections;! 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 p-rocures 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.H
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 in the  head and disturbance in the dreams: and,
  * Ludwig, Adversaria, I. i. N. 1. Bonnevault, Hantesierk Recueil, II. p. 228.
  f Cent. 1. Obs. 55.
  \ Lin. Med. 1695. p. 220.
  § Eph. Nat. Cur. Dec. I. Ann. III. Obs. 145.
  H Vater, Diss. Phosphori loco medicamenti adsumpti virtus medica. Witteb.
1751.  Tbomas, Diss, de usu Phosphori Regiom. 1762.
  5 Clinical Experiments, Histories and Dissections.  8vx>. Edinb. 1780. 
144
HJEMAT1CA.
[CL. HI.—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 practitioners about twenty to thirty years
 ago, and  numerous cases were published of the wonderful  cures
 which it perfo^ned.  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
 broth 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 venti-
lation, or the patients are numerous, fumigations with nitric or mu-
riatic 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. Mit- 
GE. IV.—SP. n.]     SANGUINEOUS FUNCTION.             145

ehell.  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 gasses 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.

                     Sguornal iFeber.

COMPOUNDED OF CAUMA AND TYPHUS : IN ITS COMMENCEMENT RESEM-
        BLING 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.—T 
146
HJEMAT1CA.
[CL. HI.—Oil. i.
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 the genus synochus,
whose type is frequently seen in this country.  Yet between the
typhus and synocha I cannot place any accurate limits ; and I doubt
whether they should  in fact be deemed genera, or have a different
place allotted them."  And in his First Lines  he observes,  " 1 am
disposed to believe that the synochus arises from the same causes
as the typhus, and is  therefore only a variety of it."   To me it ap-
pears rather to arise from the same causes as the cauma, for 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  saburral  fever.*  By Kausch, and
other German pathologists, it is hence denominated febris inflamma-
torio-putrida.f 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:
* Sudatorius.                   Carried off by a  critical sweat
  Sweating synochus.              in an  early stage of its progress.
C Flavus.                        With yellowness of the skin, at-
  Yellow synochus.                tended  with  a  sence  of burn-
                                  ing heat.
y Soporosus.                    Accompanied with stupor from
  Comatose synochus.             the beginning.
^ 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 ihe 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. 111. p. 97. 106.  113. IV. 61.
                 j Gruner, Almanack, 1788.  p. 37. 
GE. IV.—SP. Ill]    SANGUINEOUS FUNCTION.
ur
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  wi'hout 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, thai 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
interposed.  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, ana  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 head, which runs
* De Differ febr. cap. U. De Crisibus, cap. II. 
U8
HJEMATICA.
[CL. III.—OR. I.
rapidly into a state of inflammation, with an imperfect attempt at
suppuration; and especially where this membrane has been excit-
ed by a sympathetic actior^with the uterus or any other adjacent or-
gan, or by exposure to the atmosphere in consequence of a wound
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 of 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 oftr;n 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 after 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,  trou-
bled 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 recall 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 ofter delivery,  he ascribes, as his sentiments are delivered by
 Mr. Cruickshank, 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 other
 times from a too sudden emptying of the abdomen; whence  the
 peritoneum cannot always recover itself so as to be properly adapt- 
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 further remarks, that it spreads
over all the cavity of the abdomen.  An extravasation of fluid 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 autumnalis, to which the reader may turn at his leisure.f
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 epidemy4   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 where they
 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.
f See Vol. II. CI. III. Ord. I. p. 93.
} Clark, Edin. Med. Comment. Vol. III. 
150
HJEMATICA.
[CL. III.—OR. 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 of
 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 arc
 more liable to be infected  than others from incidental circumstan-
 ces; and, as I have already had occasion to observe in laying down
 the iaws 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. Cruick-
 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.f
 The nature of the fluid will, indeed, entirely depend upon  the vehe-
mence and  rapidity of the  inflammatory process.   Where this 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 slate 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 pariicipated in
• Treatise on the Puerperal Fever.
f Epist. ad Haller Script. Vol. III.
$ Hulme, ubi supra. De la Roche, Recherches, &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 the 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.  The inflammation must be subdued, and that speedily,
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 lo 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 doses
of calomel we must unite opium.  It does not follow that calomel
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  loins 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. Haffin. I. 
152
ILEMATICA.
[CL. HI.—OR. I.
tice, is warmth and moisture; the flannel answers the purpose as
well as the bread; and whilst I do not recollect a single instance in
which  this application has not been soothing and serviceable, I have
never met with a case in which a chill has been complained of.
  In the mean time, a diapnoe or breathing perspiration on the sur-
face should be attempted by small doses  of ipecacuan, united with
opium in the form of  Dover's powder, and with the addition  of a
solution of acetate of  ammonia ;* and if the debility be very consi-
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 advisable 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.
* Beytriige zur Wondarzneykunst. Band. I. 
       CLASS III.

HiEMATICA.
                         ORDER II.

                      PHLOGOTICA.

                       Knflammattons.

 FIXED HEAT AND PAIN OR SORENESS J INCREASED SECRETION; LESION OF
  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 (pxtyet, " incendo," "ango."  Lin-
 neus employs phlogistica from the same root; but as the chemists
 have long since laid hold of phlogiston, and the term, though lately
 disused, 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,
 import, in common medical language, a very different and almost an
 opposite idea, the author has also purposely passed by this term in
 order to prevent confusion. The nature of the fever accompanying
 the inflammation cannot enter into the definition; for this will vary
 with 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 have 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."*
             • On Blood and Inflammation, p. 227
Vol. II.—U 
154
HJEMATICA.
[CL. III.—OR. U.
  When an inflammation takes place near the surface of the body,
there 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
of vision.
  Inflammation in most cases appears  to begin at a point; for at
the commencement, all the local symptoms are within a very small
compass.  The spreading of the inflammation is owing to continu-
ed sympathy, the surrounding parts participating with the  point of
irritation ; 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 by excoriation, suppuration, and ulcer-
ation.
   The inflamed vessels, being thus enlarged and irritated, begin lo
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,  through new ves-
sels which may be now forming around them ; whence the sides of
the cellular membrane, which receive the effusion, become  covered
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 vessels that  contain it.
   Generally speaking,  however, it  has by all the schools of medi- 
CL. HI.—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 corpus-
 cular, to an error loci, concerning both of which we have already
 treated; the cause of obstruction in the view of either hypothesis,
 being sealed in the nature  or misdirection of the  constituent parts
 of the  blood itself: while Dr. Cullen refers it to  the same kind of
 spasms 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 inflamma-
 tion,  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 effectu-
 ally 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 actually belong, is unquestionable;  but then this is
 rather a  secondary than a  primary link in  the  chain of inflamma-
 tion,  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 dependent
 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. 
15b'
HJEMATICA.
|CL. HI.—OR. H.
 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
 before 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 thai 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 suppurated  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. HI.—OR. n.]     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 body
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 slate 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
HJEMAT1CA.
[CL. III.—OR. II
citing accessary.   And hence the real inflammatory or phlogistic
diathesis, constituting however a remote, more properly than a
proximate cause, is perhaps to be found in increased irritability of
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 few 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 habit 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 affect 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 
CL. in.—OR. II.]     SANGUINEOUS FUNCTION.
159
different effects, which, were  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. Hunler has given the names of
the adhesive, the suppurative, and the ulcerative inflammation.
  There is good reason  for this division in different heads: for
although, were 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-
ing 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 organs.   He distributes in-
flammatory affections, as I have just observed, into 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-
presma, 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 part9
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 
160
h*:matica.
[cl. in.—or. ir.
 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 ab-
 scesses cannot well be placed in either of the  genera we have thus
 far noticed ; and have a claim to be considered  by themselves.  They
 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 viris  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 putres-
 cency; 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 which the pustules will spread, but not suppurate and assume  a
livid hue, and perhaps prove fatal; while if another  person possess-
ing an uncorrupt,  and,  so  to  speak,  unbiassed constitution, be
inoculated even with this  mixed virus, the variolus 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 have 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- 
».L. HI.—OR. U.]      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 ge-
neral, 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 small-pox.  But while
the variolous diathesis is thus 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-opera-
tion, or rather in  antagonism.  It is small-pox raised  upon a consti-
tution 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  vaccine disease, even when first  communicated, becomes in
time liberated 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 rule.   We see the same
thing in the obstruction of  the natural passage of the  tears produc-
ing a fistula lachrymalis;  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, and produce inosculations with the 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 de-
scend into the nose.   In like manner, if an inflammation attack the
cellular membrane on the outside of  the rectum, near the anus,
    * See Hunter on Blood., Inflammation; &c. Part II, Chap. it.
Vol.. II.—X 
162
H^SMATIOA.
LGL. III.—OR. ii
 although the latter be in contact with the inflamed part, the inflam-
 mation will extend to the skin of the buttock, while the gut itself
 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 r 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 progress, the affected  part dies  to a certain extent; but the co-
 agulable lymph which has been thrown out, and introduced new vas-
 cularity 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 apostema, 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 
 <GE. HI.—OR. I.]      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 may 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 distention
 by local  applications that tend to contractthe diameter of the vessels,
 as cold, and metallic or other astringents; and if along with the
 distention 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 vomiting, the former of which operates
by lowering the action of  the vessels; the latter by giving a ten-
dency to a new action.  The nature of the case must determine our
choice.
                        GENUS  I.

                       APOSTEMA.

                         ^po.strmr.

large,  suppurative inflammation in a deep-seated organ ;  PUS
                    copious and confined.

The term apostema is Greek, from k^ivr^i," discedo," " abscedo,"
—whence the Latins employed abscessus, to express the same gene- 
164
ILEMATICA.
[CL. 111.—OR. II
ral idea.  Yet they did not, strictly speaking, apply either abscessu3
orapostema 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, furunculus,  and phyma.  " Sed  cum  omnes hi nihil nisi
minuti abscessus sint, generale nomen trahit latius vitium ad suppu-
rationem 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 recall 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 &])ostrmr.

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. torn. XVII. 
GE. I.—SP. I.]       SANGUINEOUS FUNCTOIN.               165

when, upon opening a patient after death, twelve pints of pus were
found effused  from a  visceral  apostume into  the  cavity of the
abdomen.*
  In all such cases the first stage of inflammation, that of 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 sailem 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 definite
 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. 
 143ti                      HEMATIC A.           [CL. III.—OR. H.

 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 fat,
 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 mouth 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 ex-
 poses the interior to the operation of the gasses 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 distention 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 distention, which
 gives way to a throbbing pain, synchronous with the dilatation 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, Cruickshank, and
Professer 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,f and almost all
who practised  antecedently to  their time; and the second  that of
M. Gaber,| 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. Hewson, 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 from
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 half way 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 consider-
able portion of the remaining half of this curious  process, and to
prove that  the solid parts contained in  the area of an  abscess, in-
* Aphor. 387.
t Instit. Chirurg.  Sect. LIV.
i Acta Taurinensia, Vol. II.
§ Treat, on the Diseases of the Army, app.
I! Experimental Inquiries, Part II. p. 118, 
168
HjEMATICA.
|CL. III.—OR. L»
 stead of being deadened by the pressure of the surrounding  pus,
 are dead befoie-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  thai 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 exem-
 plified by later physiologists, and particularly by Mr. Cruickshank
 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 primed 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
 serum,  advanced as  a  true and genuine doctrine,* without  the
 slightest hint of any newer or more satisfactory explanation of the
 subject.
  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 :f and most of all,  (to the present author, at least,
 most of all,) that his friend Dr. Parr, with all ihe 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
abscess " consists of  the substance  of the vessels, and  of the cel-
 lular  membrane 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
 Dreach 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 II. Cb. I. Sect. CCL.
t Part 1.  Sect. iii. 
»jE. I.—SP.I.]      SANGUINEOUS FUNCTION.                169

pus without  ulceration in  the  first stage of purulent ophthalmy,
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
aboul  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.   I requested Mr. Clines's attention to this case, and
we saw not the slightest reason for suspecting an 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 differ-
ent 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 de-
nied 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.
  f Vol. 1809, p. 313. See also a further description under Marasmus Phthi-
sis in the sequel of the present volume.
  t On Inflammation.—Of Pus, p. 433.
  Vol. II.—Y 
170                      HJEMATICA.            [CL. III.—OR. H'

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 towards the skin; and hence  exactly contrary to the course
of ulceration,  which always  begins in  the superior part of  an ab-
scess.  The process commonly succeds 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 ; inosculation or the attraction of  cohesion is esta-
blished 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 ap-
ply 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 1 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 n. Ch. v. p. 43p\ 
GE. I.—SP. 1.]
SANGUINEOUS FUNCTION.
171
  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  lo 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 substances 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 substances 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 hypo-
 thesis 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 m 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
H.LMAIKjA.
[CL. HI.—OR. II.
 experiment,  as he conceived, fully  established  his pre-conceived
 opinion : and gave proof that the pus of an abscess does not act as
 a solvent.  This conclusion of his only shows how difficult it is for
 the most honourable mind, when biased by a favourite hypothesis,
 to weigh with an even hand the  evidence that lies before it.   " To
 see," says he, " how far the idea was just, that dead animal matter
 was dissolved by pus, I put it to the trial of  experiment, because 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 ;f 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. II. Ch. v. p. 419.
f Dissertation on the Properties of Pus, p, 32. 
uE. I.—SP. I.]      SANGUINEOUS FUNCTION.
irs
  But I have for many years thought that it has also another equal-
ly important use ; that, I 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 gass 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 gass immediately coagulated and formed a canal,   hiv. re-
peated his observations on another plant, whose  pubescence con-
sisted of a 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 whicb, in a short time,
the gass from the first joint rushed : and thus, in a moment, a second
joint was formed.  In the same manner, he observed, the formation
of the hairs of ten 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,t 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 gass, 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 globules
were  collected, and from thence passing in  every direction  with
considerable rapidity through the serum, but not at all interfering
with the  globules themselves, which had all discharged their co-
• Phil. Trans. 1818, p. 180-194.
fVol. I. 304. 
174
H.SMATICA.
[CI., m.—OR. If
 louring matter.   Wherever this extricating 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 difficutly 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 formed."
 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 apparently by
 the same means, since  if pus  be deprived of its  carbonic acid gass,
 (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 (he gass-
 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
 internal tonic in cases of dyspepsy and cardialgia. 
GE. I.—SIMI]      SANGUINEOUS FUNCTION.               175


                       SPECIES II.

              APOSTEMA PSOATICUM.

                      JJsoas &ftscess.

(PAIN AND TENSION ABOUT THE LOINS, SHOOTING DOWN THE SPINE AND
  THIGHS," DIFFICULTY OF STANDING ERECT; FLUCTUATING ENLARGE-
  MENT ALONG  THE PSOAS MUSCLE; APEX OF THE TUMOUR IMMEDI*
  ATELY BELOW 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 many 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 j and the case has been, in a very early stage of the 
176
HJEMATICA.
[CL. lit.—OR. II.
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 cJfvity ; a subject already
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 Ihrows out
this hint, however, for future and general consideration.



                       SPECIES III.

                APOSTEMA  HEPATIS.

                   &fcscess of the Hfoer.

DIFFUSE PULSATING TUMOUR IN THE REGION OF THE LIVER; PRECEDED
         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.
  Secondly, 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. 
**E. 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 ahscess 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, andjpHiere the liver has  not  been weakened or
rendered torpid by ag^former affection.  It is hence rather to be
looked 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 certainty
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 regarded
as sufficient indications. In a case of this kind that occurred to me
in a young gentleman of about thirteen years of age, the shivering
was so considerable as to make the teeth  chatter; and within eight-
and-forty hours the pulse sunk from a hundred-and-forty to a hun-
dred-and-twenty; and the  abdominal tension and  tenderness were
considerably abated; as was also the distressing  cough with which
he had almost perpetually  been  harassed for some weeks.   He was
put upon a tonic plan of columbo and sulphuric acid immediately
after this change, and recovered gradually.
Vol. II.— ^ 
178                      H^MATICA.          [<JL. III.—OK. II


                       SPECIES  IV.

               APOSTEMA EMPYEMA.

            aotrgment of fatter in the Ghent

FJXT PAIN IN THE CHEST ; BREATHING LABORIOUS, BUT EASIEST IN AN
  ERECT POSITION ; DIFFICULT DECUMBITURE ON THE SOUND SIDE J
  FLUCTUATING ENLARGEMENT ON THE SIDE AFFECTED ; DRY TICK-
  LING  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 first
two  belong rather to the hectic fever thar*generally accompanies
empyema, than to the disease itself.  The last has sometimes been
met with in modern times.f Dr.  Cullen regards empyema as a mere
sequel of pneumonia, wtiich with him  includes inflammation of 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, peri-
cardium, 8cc." 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
• Tltfi n*9»v, p. 476.496.
f Trecourt Memoires de Chirugie, &c, 
6E. I.-SP. IV.]      SANGUINEOUS FUNCTION.              179

were employed by his friends to encourage him, by advising him
' not to be afraid.'  By which good advice he conceived so much
fear that he  ran away early next morning, and returned in about  c
week quite well."
  This should indicate that something may at times be accompi' v
cd  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,i 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
pointing and bursting under the scapula.||  Morgagni has recorded
a singular case of a  double empyema, a lodgement of pus  being
formed on both sides.! 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.|J:  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 direct.HIT
  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.
  f Buchner,  Diss,  sistens solutionem Empyematis per mictionem purulen-
tam.  Hal. 1762.  N. Act. Nat. Cur. Vol. I. Obs. 5.
  * Schlichting, Phil. Trans. Vol. XLI1. p. 70.
  § Hautesierk, Recueil. II. p. 239.
  K Hurten, Diss, de Empyemate.  Argeat. 1679.
  5 De Sed. et. Caus. Morb. Ep. XXII. Art. 13.
  ** Journ. de Medicine, torn. LXV1.  p. 244.
  |f ntpiiovo-en, II  p. 476. 1.42.  TIipi w «v8o; n*8«v,  p. r>3&. 1. 15.
  ** Cent I. Obs. 72.
  $§ Mem. pour le Prix de l'Academie, X.
  ]|U Critical Enquiry, &c. Chap. VI.
  •if  Surgery, Vol. II. 390. 
Jg(j                      ILLMATHJA.            (UL. III.—OB. H.

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 'T 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 pa-
racentesis the old fashioned practice ought still to prevail.f
  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 and 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.§
  The matter when discharged or  examined on dissection has been
found,  as may be easily supposed, of very different consistencies;
sometimes 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
  * See Phil. Trans. Vol. XLVU. XLVIII. LI. as also his works in their col
lected form.
  f Surgery, Vol. II.  ch. XXII. Sec. IV.
  * Edin. Med. and Surg. Journ. No. LXI. p. 513.
  § Lin. Med. Ann. V. Obs. 30.
  H Heuermann,  Vermichta Bemenhungen, II. p. 217. 
GE. I.—SP. V.]     SANGUINEOUS  FUNCTION.              181

on the affected side  totally eroded;* and in one  case the pericar-
dium destroyed as well as the lung.f
                       SPECIES V.

                APOSTEMA  VOMICA

                           ©omfca.

DERANGED FUNCTION OF ATHORACIC OR ABDOMINAL ORGAN; SUCCEED-
  ED BY A COPIOUS DISCHARGE OF PUS INTO SOME PART OF THE ALI-
  MENTARY CHANNEL; AND ITS EVACUATION BYTHE MOUTH ORANUS.

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 is 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.i.
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, "vomicae clausae."  Linneus
and Vogel, on the contrary, while they confine  the  term to the
lungs, explain it by open vomicae " vomicae  aperlae,"  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, lo 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,
           f Goeckel,  Gallicinium Medico-pract.'
           t De Medicim Lib. IV.  Cap. viii. 
182
ILEMAT1CA.
CL. HI.—OK. "■
  Bartholine gives a singular case of an occult vomica of the lung9,
that, accompanied with an asthma, produced great emaciation; but
was fortunately cured by the wound of a sword, the point of which
passed between the ribs and opened the sac.  A considerable flow
of pus followed, and the patient recovered gradually from the time
of the accident.*
                       GENUS  II.

                      PHLEGMONE.

                        ^lUrflmon.

 SUPPURATIVE, CUTANEOUS TUMOUR; TENSIVE; GLABROUS;  PAINFUL;
  AT LENGTH FLUOTUATING,  AND BURSTING  SPONTANEOUSLY J  THE
  PUS UNIFORM 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  Qhiyu, " 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.               185

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  CUMMUNIS.        PUSH.
2.---------PARULIS.            GUM BOIL.
3. ---->      AURIS.              JMPOSTHUME IN THE HEAD.
4. --------- PAROTIDEA.          PAROTID PHLEGMON.
5.---------MAMMJE.            ABSCESS OF THE BREAST.
6. --------- BUBO.              BUBO.
7.---------rHIMOTK'A.          PHIMOTIC PHLEGMON.
                        SPECIES I.


             PHLEGMONE  COMMUNIS.


                $usfi. Common Pileflmon.

TUMOUR COMMON TO THE  SURFACE; BRIGHT-RED;  HARD ; DEFINED ',
  HEMISPHERICAL ; POLARIZED J GRADUALLY SOFTENING AND BURST-
  ING AT THE POLE.

In vernacular language this species is denominated Kpush ; 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 weJJ as from other circumstances, not unfre-
quently to inhere in the temperament  we are now contemplating. 
184
H.LMATICA.
LC L. Ill—OR. II
                       SPECIES II.

               PHLEGMONE PARULIS.

                        (Srttm-ttofl.

I'UMOUR SEATED ON THE GUMSJ DEEP-RED; HARDISH; UNDEFINED ; PAIN
                          OBTUSE.

This is sometimes limited to 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 sapientiae  : the swelling from the violence
of the irritation, spreads rapidly  and widely;  so that  the entire
cheek is  sometimes involved in it, the  neck  indurated, and  the
eye closed.
                      SPECIES III.

               PHLEGMONE  AURIS.

                 Xmjjosnumc fn the ?l?cau.

1UMOUR 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. HI.]    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 bones
carious.
                       SPECIES  IV.

            PHLEGMONE PAROTIDEA.

                    iJavottti  liMilcQmon.

TUMOUR SEATED UNDER THE EAR J REDDISH; HARD; PAIN OBTUSE;
               SUPPURATION 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
of 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 heal 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.—A a 
186"                      H2EMATICA.            [GL. Hi.—OR. H.

  Phlegmonous inflammation of the parotid gland offers us the two
following varieties:—

* Simplex.                      Incarning and cicatrizing easily.
  Simple parotid phlegmon.
|3 Maligna.                      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 and 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 ace-
tatis 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;f and the Transactions of Natural Curiosities,
by the bladder.!  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.
•J- Obs. Chirurg. Facie. I.
t Vol. I. Obs. j9.
§ Cellezione di Oasi Chirurgici, I. 447.
B Histoire et Memoirs de l'Academie de Toulouse, torn, L 1782. 
■GE. H—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 suc-
cess, when upwards of three pounds in weight;* sometimes with a
cure;f but at other times it has degenerated into a foul, bleeding,
extensive, and fatal ulcer.f
                        SPECIES  V.

               PHLEGMONE MAMMAE.

                   &fcsces<3 of the  breast.

tumour seated in the breast; tale red ; hardish ; 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
severe pressure;  but more generally proceeds from a redundancy
and consequently undue stimulus of milk, when first secreted after
child-birth, so that the lacteal tubes have not time to enlarge suffi-
ciently for its  reception: in  which last case  it is usually called
milk-abscess.—" In either case the suppuration commonly begins
in many distinct portions of the inflamed part;  so that it is not one
large circumscribed abscess, but many  separate sinuses, all of which
generally communicate.  Now it usually happens  that only one of
these points externally, which being  either opened or allowed  to
break, the whole of the matter is to be  discharged this way.  But
we sometimes find that  the matter does  not find a ready outlet by
this opening, and then one or more of these different sinuses make
distinct openings for themselves."§
   In this case the complaint is usually protracted and tedious,though,
where the constitution is good, and there  is no lurking taint to inter-
mix itself with the inflammation, the issue is always favourable.
   This sort of phlegmon was called by Dioscorides, sparganosis,from
the Greek term a-7ra^yaa, " tumeo, distendo;" and after him it has
still been so denominated by various modern writers.  Sparganosis,
however, was employed  by Dioscorides in a  collective sense,  to
signify not only milk-abscess, but a variety of tumours, and other
  * Kalthchmied, Pr. de Tumore scirrhoso trium cum quadrante librarum
glandulx Parotidis extirpata.  Jen. 1752.
  f Siebold, Parotidis scirrhosae feliciter extirpate Historia, Erf*. 1791.
  $ Commerc. Lit. Nor. 1733-8.
  § Hunter, on Blood, p. 469. 
188
H^MATICA.
[eL. III.—OR.H.
diseases supposed to depend upon an overflow, suppression, misdi-
rection, or depraved secretion of milk; and especially those which
have since been described  under the  general term galactirrhoea.
Many of these have little or no connexion  with  each other; and
particularly abscess of the breast, and that peculiar swelling of the
lower limb which occasionally takes place soon after child-birth, to
which the term is etymologically best applied, and to which there-
fore it is restrained in the present system.
                       SPECIES VI.

                 PHLEGMONE  BUBO.

                           ttulio

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

Bubo is a Greek term borrowed from the Hebrew verb $2 or nj,'J
(bo or boa,)  importing " to swell," and merely doubled according
to the analogy of the language, to give it an intense or superlative
power, whence bobo, or bubo.
  Buboes are chiefly found in  the inguinal and auxiliary glands.
They are sometimes simple glandular inflammations, unconnected
with any constitutional or foreign  evil, and  require nothing more
than the common treatment; but they  are often a result of consti-
tutional affection, and very frequently a symptom of lues and pestis,
in which cases they  can only be  cured by curing the specific taint.
Mr. Hunter  asserts  that he has seen buboes cured by vomits after
suppuration  has advanced.
  In an early stage the inguinal  bubo has been confounded with a
scrofulous tumour.    A  nice  finger  will  generally discriminate
them with ease.  The bubonous tumour is  smooth, uniform, and
obtusely  painful; the scrofulous is, to the touch, and sometimes
to the eye, a cluster of small tubercles  without pain. 
GE. II.—SP. VH.]     SANGUINEOUS FUNCTION.              189


                       SPECIES VII.

             PHLEGMONE  PHIMOTICA.

                    Pumotfc puesmon.

 I'UMOUR  SEATED IN THE PREPUCE ;  DIFFUSE ; OBTUSELY  PAINFUL J
    IMPRISONING THE GLANS, OR STRANGLING IT BY RETRACTION.

 If at the attack of inflammation the prepuce be in its natural state
 and cover the glans, it cannot be drawn back and the glans is im-
 prisoned.  If it should  accidentally have been retracted, or be na-
 turally 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:
 * Incarcerans.                The prepuce protracted and impri-
   Incarcerating phimosis.        soning the glans.
 /3 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 cir-
 cumligalura.  But the inflammation is one and the same,  and the
 same specific name should express it; for the difference is a mere
 accident.
   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 andblennorrhoea.  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 ihe prepuce be  retracted  violently, and the  glans
 strangulated, and cold applications, and topical bleedings prove  in-
 effectual, 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
 dissolved 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  be-
 handeln.  A D.B.XCV. 421. 
196
H-KMATICA.
[CL. 111.—OR. 11.
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.!
                      GENUS  III.

                         PHYMA.

                         arufcrrcle.

IMPERFECTLY SUPPURATIVE, CUTANEOUS, OR SUBCUTANEOUS TUMOUR ;
  THE ABSCESS THICKENED, AND INDURATED AT THE EDGE J  OFTEN
  WITH A CORE IN THE MIDDLE.

Phyma, a Greek term importing a tubercle or small swelling, from
Qw,  " produco, erumpo," was used among the Greek and Roman
physicians with great latitude and no small want of precision : some-
times, as by Hippocrates and Paulus of  ^Egina, being applied to
scrofulous,  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  and 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 wrhers have, hence, been at a loss in what exact signifi-
cation phyma should be employed. Linn6us and Cullen have reject-
ed it.  Sauvages aiad 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 lumours; and, as a genus, it thus occurs in Dr. Willart's
• Andree, on the Gonorrhoea.—Hecker, Von Venerischen Krankheisten, &c.
f Vol. V. Art. xxxvi. 
GE. HI.—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 it:—

1. PHYMA HORDEOLUM.                 STY.
2.----— FURUNCULUS.                 BOIL.
3. ------ SYCOSIS.                     FICOUS PHYMA.
4. ------ ANTHRAX.                     CARBUNCLE.
                        SPECIES  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 English  derivation, stigh, but
Spenser, 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 stt.

   From the hardness of the margin of the tumour, and the imper-
fection of the suppurative process, Sauvages compares it to a small
boil: and asserts that it is often the result of a morbid state of the
stomach; adding that he knew a man who uniformly had a sty after
drinking ardent  spirits.   The  inflammation, though often very
troublesome while it lasts,  for the  most part readily subsides upon
the breaking the minute abscess, or puncturing it at its apex when
mature. 
192
HJEMATICA.
[ CL. IU.—OR. II.
                       SPECIES II.

               PHYMA FURUNCULUS.



 TUMOUR COMMON TO THE SURFACE; DEEP-RED; HARD; CIRCUMSCRIB-
  ED ;  ACUTELY TENDER TO THE TOUCH ;  SUPPURATING WITH A CEN-
  TRAL CORE.

 The boil is a push with a central core :  and like the push is found
 in persons of an entonic or phlogotic habit, with a peculiar suscep-
 tibility of irritation: on which account it often makes its appear-
 ance successively in different parts of  the body,  and sometimes
 synchronously,  so that we meet with a crop at a time   This  tu-
 mour is therefore chiefly found in persons of high health and in  the
 vigour of youth.
  The existence of a core offers a singularity in this affection that
 is well  worth attending to, and shows that from some cause or other
 the  ulcerative part of the process is imperfect. Upon Mr. Hunter's
 hypothesis, this must depend upon a weak action of the absorbents ;
but  as we have already endeavoured to show that the material to be
removed  must  be  prepared for absorption and conveyed  to  the
mouths of the absorbent vessels before absorption can take place,
and  have suggested that it seems to be the office of the secreted pus
to accomplish this purpose, it  is probable that in  the  furunculus
 the  pus, from some cause or other, is not  quite genuine, and is pos-
sessed of a less solvent power than  in common abscesses :  whence
a part of the dead matter remains attached to the living after  the
hollow has burst, and is thrown off from the base by sloughing.
  The  mode of treatment is simple, and rarely requires medical or
 surgical assistance:  though the diathesis should  be  lowered  by
bleeding, or purging, or both.
                      SPECIES III.

                  PHYMA  SYCOSIS.

                     iPfcous ^ngma.

TUMOUR EXCRESCENT,  FLESHY; FIG-SHAPED;  SPROUTING FROM THE
  HAIRY PARTS OF THE HEAD OR FACE; GREGARIOUS; OFTEN OOALES-
  ING ; DISCHARGE PARTIAL AND SANIOUS.

The Greeks gave the name of sycosis from <tvk»i " a fig," to vari- 
GE. IU.—SP. III.]    SANGUINEOUS FUNCTION.               198

ous tubercles and excrescences, the shape of which was conceived
to resemble that of a fig.  By Celsus,  however, it is  limited to a
particular kind of inflammatory, and imperfectly suppurative tuber-
cle of the head or face.   Vogel has understood the term nearly in
the same sense; and Dr. Bateman has, hence, correctly described
it as such in his list of cutaneous diseases.
  It is seated sometimes on the beard, and sometimes in the hair of
the head.   In the former case it consists of small tumours, hard,
roundish, pea-sized;  commonly in clusters; occasionally confluent
or running  into one another; and spreading from ear to ear;  the
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 art 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.

                        earfjunclc.

1UM0UR COMMON TO THE  SURFACE; FLAT; FIRM;  BURNING} PENE-
  TRANT ;  LIVID AND VESICULAR ; OR CRUSTY ABOVE, WITH A SORDID
  GANGRENOUS CORE BELOW ; IMPERFECTLY SUPPURATIVE.

Anthrax  is a Greek term correspondent to the Latin carbunculus
or carbuncle; literally a small live-coal, so denominated from the
redness and fiery heat of the inflammation.
  The specific definition sufficiently points out its relation to the fu-
runcle or  boil, especially when  the latter assumes an unkindly or
malignant character from  something peculiar in the  part or in the
constitution. "The inflammation  that produces the carbuncle is,
however, of a different nature from  any of the former: it is station-
ary, observes Mr. Hunter, with respect to place, and is pretty much
circumscribed, forming a broad, flat, firm tumour.  It begins in the
skin, almost like a pimple, and goes deeper and deeper, spreading
with a broad base under the skin in the cellular membrane.  It pro-
duces a suppuration, but  not an abscess;  somewhat  similar to the
  Vol. II.—B b 
194
HvEMATICA.
CL. HI.—OR. H,
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:
» Pruna.             With  a black crust; and oozing an  erosive
  Escar-carbuncle.      ichor, or sanies.
/3 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 rtet^^oi  of the Greeks, the pinus Abies,
Linn, named by  the Latins terebinthus;  whence it has been called
terminthus and terebinthus indifferently.
  As  the carbuncle is an inflammation of great weakness set down
on a peculiar predisposition,  it sometimes shows itself among feeble
infants in warm climates.  According to Tournefort, in his Travels
through the Levant, it attacks them chjefly in  the back part of the
throat, and proves quickly fatal.  He describes it as endemic in his
day among the islands of the Archipelago.
  In  more advanced life, for the same general reason, we meet with
it frequently  in those who have debilitated their frames by an excess
of good living, and are verging on the feebleness of age.   We may
hence also account for its appearing in an early stage of the  plague,
the most debilitating  disease in the whole catalogue.  It  sometimes
* On Blood, Inflammation, &c. Part. II. Ch. IV 
£E. HI.—SP. TV.]    SANGUINEOUS FUNCTION.
195
shows itself in great numbers almost on its onset, or m' drop as the
Arabians call it, who distinguish carbuncles by the name of jimme-
rat.
  When unconnected with  any other disease, a cure has been at-
tempted by local stimulants, as cataplasms of tobacco and sal ammo-
niac, which has been  a common practice  in Russia; or of horse-ra-
dish,* or stone-crop (sedum acre.)f  Cantharides,|: camphor oint-
ments, and lotions of zinc  or  mercury have also been tried.  To
which,  as in the case of cancer,  has  been sometimes added the
sucking of toads : as though it were possible to draw out the lurking
virus with the swallowed humours.  More  generally, however,  it
has been attempted to be destroyed or extirpated.   Arsenic was re-
commended for this purpose as early as  the age of Agricola; and
has been employed in  various forms, from that of orpiment to that  of
Plunket's caustic: above all which, however, Le Dran preferred
corrosive sublimate.  Riverius used other caustics, and 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.

                           Whelfe.

UNSUPPURATIVE, TUBERCULAR TUMOUR ; STATIONARY ; CHIEFLY COM-
                       MON TO THE FACE.

Ionthus (/ov0«$) is literally a violet, or  purple eruption, or efflores-
• Pare", Lib. XXI. cap. 32.
f Buchoz und Marquet neueste Heilkunde, Niirnb. 1777.
i Riverius, Observ. Med. lent. IV. 
j 95                     I1JRMATICA.           LCL. HI.—OR. II.

cence," from <*v, 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 maybe compre-
hended under the two following species :—

J.  IONTHUS VARUS.             STONE POCK.
2.  «-.■ .  . - CORYMBIFER.        CARBUNCLED FACE.  ROSY DROP.
                        SPECIES I.


                  IONTHUS VARUS.

                       Stonc=$ocfc.

jumour red; hard; pimply; distinct; gregarious; sore to the
     touch ; 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:—-

tt Simplex.        Broad-based, bright-red, solid.
  Simple Varus.
£ 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 concrets 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 to the stomach ; as acrimony, or a sudden  chill from 
GE. IV.—SP. I.]     SANGUINEOUS FUNCTION.               1J7

taking a draught of cold water or cold milk; or eating cold vegeta-
bles, as turnips, cucumbers, and melons, when in a state of great
heat and perspiration.   Catching  cold in the  feet has sometimes
produced the same effect.  These are cases of direct sympathy: the
torpitude 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
daily for ten days or a fortnight.  But they generally require some
local irritant at the same time,  as savine cerate, the camphor or
mercurial liniment, or the stronger liniment of ammonia, used so as
to excite 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 spon-
taneously.  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 pimples over  the greatest part of her face, in vain.  She
took rhubarb five  grains, and emetic tartar a  quarter of a grain,
every night for many weeks, and blistered her face by degrees, all
over, and became quite beautiful."*
                        SPECIES II.

              IONTHUS  CORYMBIFER.

              <Earfmwcletr=face.  Jfcosg 31roj>.

tumours confluent; corymbose; MOTTLED WITH PURPLE; OFTEN1
       DISFIGURING THE NOSTRILS WITH PENDULOUS LOBES.

As the preceding species 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 disfigured, have indulg-
* Zoonom. CI. II. I. iv. 6. 
198
HiEMATICA.
[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 lhat
" 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
suddenly, for this would run a risk of producing dropsy, and,  per-
haps, 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 bowels 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 recruit the spirits and  invigorate the system generally, in
which  benefit the liver will become a chief participant.   The tu-
mours may not, perhaps, totally disappear: but they will  often di-
minish in magnitude, and  assume a healthier hue: or at least we
shall  hereby prevent them from  any farther enlargement, and es-
pecially from passing into that  carbuncular ulceration we have just
noticed.
                       GENUS  V.

                        PHLYSIS.

ulcerative, subcutaneous tumour ; flat ; tensive;  glabrous;
  diffused; hot; throbbing; at length fluctuating with an
  acrid ichor.

Phlysis, from the Greek Qxvty, " 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, derived 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 spe-
cies, the paronychia, or whitlow. 
GE. V.—SP. I.]     SANGUINEOUS FUNCTION.
199
                        SPECIES I.

              PHLYSIS  PARONYCHIA.

                         ablution).

INFLAMMATION SEATED ABOUT THE NAILS AND ENDS OF THE FINGERS 5
     '   PAIN ACUTE AND PRICKING, SHOOTING UP THE HAND.

Under this species are included the following varieties :
k Cutanea.                     Effusion immediately under the
  Cutaneous whitlow.              skin.
/9 Tendinis.                    Effusion among the tendons.
  Tendinous whitlow.
y Periostii.                    Effusion pressing on the perios-
  Malignant whitlow.             teum.

  In the first variety, the acrid effusion 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 
800
IIAMATICA.
[CL. HI.—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 ;f and Mr. John  Pear-
 son has shown that it may occasionally result from  a syphilitic dia-
 thesis or any other depraved habit4   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.

                    Xnflammatorg ittusft

RED, GLABROUS, TUMID FULNESS OF THE INTEGUMENTS J DISAPPEARING
  ON PRESSURE : PAIN BURNING ; INFLAMMATION ULCERATIVE ; TERMI-
  NATING IN CUTICULAR SCALES, OR VESICLES ; OCCASIONALLY IN GAN-
  GRENES.

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 eptv6ot, 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.
f Chirurgisches Tagebuch. XI.
i. Principles of Surgery, P. I, 
GE. VI.]
SANGUINEOUS FUNCTION.
901
 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 erysipelatesa. And
 hence erysipelas  has  been made a very  common synonym of ery-
 thema by general writers, while the nosologists, with a few excep-
 tions, have limited erysipelas to that species ef 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 pyrexia is merely
 symptomatic.
   Frequently, however, as these two disorders have been confound-
 ed, from an indiscriminate application of the same name to 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 commonly 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 oedematosum.       edematous inflammation.
 2.--------erysipelatosum.   erysipelatous inflammation.
 3. ________ 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. II.—C c 
202
HEMATIC A.
[CL. HI-OR. U.
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 to.  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 stales, dry and 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 Tutnoribus, Prater. Nat. torn. in. xx. 
HE. VI.—SP. I.]     SANGUINEOUS FUNCTION.               30;*


                        SPECIES I.

           ERYTHEMA (EDEMATOSUM.

                SStJematous Knflammatioit

COLOUR SCARLET;  SPREADING WIDELY AND DEEPLY THROUGH THE
   CELLULAR MEMBRANE, WHICH OFTEN  IMPERFECTLY SUPPURATES,
   SLOUGHS, AND BECOMES GANGRENOUS.

This is the " edematous inflammation" of Mr.  Hunter, who ob-
serves, that, when the extravasated 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 the pressure of the
fineer, 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 orobably goes much  deeper: for the extravasated  fluid is in too
laree 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
euide 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
Drinciple 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 distention,  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 m  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 no longer continuance.  Suppurative inflammation is, generally

             *  On Blood, Part H. Ch. H. Sect. vii. p. 269. 
204
HJEMATICA.
[CL. HI.—OR. II
speaking, the process of a  healthy part  or  habit taking place 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.
  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.

               -Srgsfjtelatous inflammation.

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 AF
  FECTED.

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 have 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 in 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 is
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 inflammation 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  in 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 true
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. II.
t Comment, torn. II.  «■ 723. 
206
HJEMATICA.
[CL. III.—OR. H.
 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
 equal parts of starch and finely levigaied  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 separated
 cuticle.
   This species of inflammation sometimes attacks infants from a
 very early period  after birth ;  and, whai 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 crepitation.  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 GANGRENOSUM.

               ©ansrenons inflammation.

THE  COLOUR DUSKY-RED; SUPERFICIAL; CUTICLE SEPARATED FROM
  THE CUTIS BY A  BLOODY SERUM; THE CUTIS, WHEN DENUDED, EX-
  HIBITING DARK BROWN SPOTS, DISPOSED TO BLISTER, AND SLOUGH;
  OCCURRING CHIEFLY  IN THE EXTREMITIES.

The gangrenous erythema, like the two preceding species, is a fre 
CE. VI.—SP. m.]     SANGUINEOUS FUNCTION.              207

quent companion of debilitated or relaxed constitutions, but is most-
ly o be met with in advanced age, or weakly adolescence, or in-
fancv; 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-
:.'?arance.  The inflammatory stage is in  these cases  sometimes
\ ery slight, and the gangrene is ushered in with very little previous
affection.
  Either of the preceding species will pass readily into the present,
in a warm, stagnant, and corrupt air ; for the same reason that all
hospital wounds run rapidly into the same stale under the same cir-
cumstances, as we shall have to notice hereafter.
  Loca! applications are here of far less importance than an atten-
tion to the general  condition of the constitution.   Stimulants and
pevffct cleanliness are perhaps all that are demanded  under the
first bead; while, under the second, pure air, and a steady course
of  'onic medicines  and diet, adapted to the age and habits of the
patient, 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 VESIOULARE

                   Vesicular JSrstnema.

colour pale-red; surfaceroughish, and covered  with crowd-
   ing 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.
     £ 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  heal-
 ing.
   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
HJEMAT1CA.
[CL. 111.—OR. a.
 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 erysipelatous 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
 example; but the ignis sacer, in its genuine and simple state, in-
 stead 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 ephe-
 meral or any other fever which  may give increased action to the
 system ;  hereby proving  that this,  like the entire group of erythe-
 mas, is a result of debility.
   In ancient times some diseases were supposed to be inflicted upon
 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
 supposed agents of the deity whose names they respectively bear.
 Ignis is a term expressive of the heat, redness, acrimony, and  ero-
 sive 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 presents it as a
 genus comprising two species, the first of which is precisely paral-
 lel with the species before us, and the second with the erythema
gangrenosum, or the preceding;  and, in order to prevent any doubt
 upon this subject, the definitions of  both species are  here given, as
 nearly as may be, in the words of Celsus himself. " It has," says
 he, "twospecies;  one  (the vascular 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 Medicin. Lib. v. Cap. XXVIH. Sect 4. 
 «-.E. \I.—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 * 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 corres-
 ponding with the variety p.  Celsus then passes on to describe  his
 second species, which answers to the character and almost to  the
 words of erythema gangrenosum, or that we have just considered.
 " The other species," says he, " consists in an ulceration of the  cu-
 ticle,  without depth, broad, sublivid, but unequally so ; and the mid-
 dle 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 <p*vx.Tcuvctt 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 qxvktxmxi, or vesicles, as the peculiar cha-
 racter of the eruption.  " Yet the body," says Thucydides, " was
 not outwardly very hot to the touch, nor pale;  but reddish, livid,
 and efflorescing with minute  phlyctaenae  (vesicles)  and ulcers;"*
 which Lucretius has thus forcibly rendered:

         Et simul ulceribus quasi inustis, omne rubere
         Corpus, ut est, per membra saceu quom diditur ignis.
         Wide-ting'd with  purple dye, and brandish'd o'er
         With trails of caustic ulcers, like the blaze
         Strew'd by the holt fire.

 It is perfectly clear, then, I think, that the ignis sacer of the Roman
 writers was an erythema,  chiefly vesicular, and sometimes gangre-
 nous.  It is also perfectly clear, that  the present, like the preced-
 ing, species of erythema  is the result of  local or  general debility,
 and requires warm and active  local applications, and a  tonic and
 bracing regimen.
   Where the skin is  slightly  broken,  and  the acrid fluid oozes
 through  the minute openings, the vesications should be frequently
 dusted, as  already recommended under the  second species, with
 chalk,  or starch ; or, where the latter is too harsh  and drying, with
a mixture of equal parts of starch and finely levigated  calamine ;
fcarefully 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 limes,  as
Vol. IL—D d
* Hist, II. 50. 
210
HJEMATICA.           [CL. HI.—OR. II
a symptom in plague;  it is  also occasionally found, in the one  01
other of its varieties, as a sequel on  the exhibition of mercury in
irritable habits; and, under this form, has been occasionally  denomi-
nated by authors erythema mercuriale, and hydrargyria, as  we shall
have occasion to notice still  further when treating of syphilis
                        SPECIES  V.


                ERYTHEMA  PERNIO.



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

This species offers us the two following varieties:

x Simplex.                 The cuticle remaining unbroken-
  Simple Chilblain.
fi 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 charac-
ter or the age and constitution in which it is chiefly to be met with,
and from the stimulant mode of treatment by which alone it is to be
cured.
  The proximate cause of chilblains is a diminution of  the excita-
bility or vital energy of the  extreme vessels; and as such diminu-
tion  is most readily produced  in  children, or  older  persons of
relaxed fibres, these are most subject to the  disease.  For though
we often meet with it also  in strong  and hardy boys, it will usually
be found that the last, from the natural vigour and courage of their
frames, have braved the cold and rigid reign of the winter-season
beyond the venture of their school-fellows.
  Local stimulants then  are  the only applications that will answer ;
and particularly those  which serve at the same time to defend the
weakened organ from the  severity  of the external air.  Hence, 
GE. VI.--8P. V.]   SANGUINEOUS FUNCTION.                $11

dog-skin socks worn day and night are useful, and warm d^lon,
or Burgundy pitch, spread upon  leather, still more bo..For he
same reason embrocations of spirits of turpentine, opodeldoc, liquor
ammoni* 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.

               jpret.   _roston of the Sntn.

 r-OLOUR OF THE INFLAMED PART BRIGHT RED ; CUTICLE ERODED ; THE
      EXPOSED SKIN OOZrNG A LIMPID AND  ACRIMONIOUS FLUID.

 The fret or erosion which frequently takes place in different parts
 of the skin from an acrid secretion of the exhalants  or sebaceous
 elands, 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 a weak vascular action, and
 often considerable irritability in consequence of such weakness.
   The most common example of this species is that which takes
 mace behind the ears of children of a delicate habit,  or who labour
 Snder 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
 Brevent 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 subdued 
212                      1LEMATICA.            [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 a-:
one of those in most common use.

                                ■^

                      GENUS  VII.

                       EMPRESMA.

                   Stfsceval  Xnflammatfon.

DERANGED FUNCTION OF A VISCERAL ORGAN, MEMBRANOUS OR PAREN-
  CHYMATOUS ; WITH LOCAL PAIN ; FEVER MOSTLY A CAUMA ;  INFLAM-
  MATION MOSTLY ADHESIVE.

The genus of diseases upon which we now enter consists of  that
numerous collection of visceral inflammations which, from the  time
of Boerhaave,  have been generally  distinguished  by anatomical
terms derived from the organ affected, with  the  Greek  term itis
added as a suffix, as cephalitis,  gastritis, carditis  and  many others.
It is is sufficiently  significant  of its  purpose:  it is immediately
derived from itpMt, which is  itself  a ramification  from  tu,  -and
imports, not merely action, "putting or going forth," which is the
strict and simple  meaning of  tu, but action in its fullest urgency,
"violent or impetuous action."  As  a suffix,  therefore, we  shall
retain it in  its common use, and proscribe it, to prevent confusion,
from the f§w compounds,  or proscribe the compounds themselves,
in which this common use is  departed from :  as rachitis, hydro-
rachitis, ascites, and tympanites, none of which convey any idea of
violent or impetuous  action, and  some of which are peculiarly
marked by a contrary state.
  This application of a common term in composition to so large a
body of visceral inflammations, and the general  use of the  term for
so long a period as that throughout which it has been employed, is
a sufficient proof that practitioners have discovered between these
inflammations other  features  of resemblance than  the   general
symptoms of inflammatory disorder.   In the  prosecution of the
subject, we shall find that this is the fact;  and I  have  already
observed, towards  the commencement of  the present  order,  that,
with a very few  exceptions, the inflammation in all  the diseases is
of the adhesive kind, and  the fever a cauma.
   With a view,  therefore, of simplifying, as far as simplicity  may-
be of real use, the present system will, for the first time, comprize
the whole of these under one  genus, here distinguished  by the
name of empresma, or " internal inflammation," a term, in its simple
form, employed both by Hippocrates and Galen ;  and which it seems
  iecessary 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, sym-
pathize with each other, and most of them with the stomach. The
necessary consequence of which is, that the constitution is disturb-
ed  generally,  though in  very  different degrees according  to the
organ affected; or, in Mr. Hunter's opinion, according to the dif-
ferent degree of its connexion with the stomach.
  If the heart, the lungs, or the brain be inflamed, whether  prima-
rily or secondarily, as by sympathy, the stomach is peculiarly in-
fluenced,  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 cases 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 its very beginning, it has the same effect upon the constitution as
a farther advance of an inflammation in other organs that is equally
sure of proving fatal in its result.  The debility commences early,
because  the inflammation  itself  is immediately  interfering with
actions essential to the life;  and, as already observed, the sympathy
between those 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
ILEMATICA.           [CL. III.—OR. H.
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 ver\ essen-
tial 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 parts, and espe-
cially upon the character of  the constitution :  for if the last be ex-
tremely irritable and weak, as  in many women who lead sedentary
lives, the pulse may be as quick, hard, and small, even at the com-
mencement of the inflammation, as in inflammation of the vital parts.
The blood, moreover, may be sizy, but will be  loose and flat on the
surface.
  Having premised these  general remarks, we are the better pre-
pared for examining the relations which the numerous species be-
longing to the present  genus bear to each other; and satisfy our-
selves with a more  summary account of several of them than would
otherwise be necessary.
                        SPECIES I.

             EMPRESMA CEPHALITIS.

                Knflammatton of the  Brain.

PAIN IN THE HEAD; AVERSION TO LIGHT; FACE MORE OR LESS FLUSH-
                         ED; CAUMA.

The pathology of cephalitis, or inflammation of the brain, is, in
some degree, obscure and difficult, from the  difference which occurs
in several of its secondary or concomitant  symptoms;  occasioned
partly, perhaps by the difference of its exciting cause, partly by the
particular portion of the organ that is primarily or chiefly affectedr
and partly by  circumstances which seem  lo  baffle  all research.
From this occasional  difference of symptoms some nosologists have
endeavoured to establish as many distinct affections, and have hence
multiplied a single specific disease  into a  considerable number of
distinct species, and. even genera, and treated of it under a fearfu' 
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 membranes 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 h':at, 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:

« Meningica.                 Pain in the head acute;  intolerance
  Phrenzy.                     of light and sound; cheeks perma-
  Brain-fever.                  nently flushed ;  eyes  red ; watch-
                               fulness; delirium; pulse rapid.
C Profunda.                  Pain in the head obtuse; cheeks ir-
  Deep-seated inflammation     regularly flushed; pulse irregu-
    of the Brain;              larly  frequent;  eyes  oblique;
  Acute Dropsy of the Head.   sleep heavy  but unquiet, and oc-
                               casionally interrupted by screams^
                               Chiefly common to children.

  The above clear and distinctive marks, however, by which the
two varieties are separated from each other in exact cases are not
often to be met with ; as each, for reasons already given, is apt to
assume something of the character of the other.   And hence they
have hitherto  escaped the attention of all our nosologists, even of
those who have subdivided inflammation of the brain into the great-
est number of distinct genera  or species of disease; whilst Vogel
expressly declares that all  the most acknowledged symptoms of in-
flammation of the brain are equivocal, not only as to a distinction of
one morbid part from another, but as indicative of  inflammation in
any part; and Dr.  Cullen  asserts in a note subjoined to his generic
definition (for he advances the disease to the rank of a genus, and
* Hunter, on Blood, &c. p. 288. 289. 
216
HjEMATICA.
tCL. 111.—OR. 11.
 a genus too without a species or a specific character,) that there
 are no symptoms capable at all times of distinguishing, with certain-
 ty,  inflammation of the brain from inflammation of its meninges.
 On which account he deviates from the more complicated arrange-
 ments of Sauvages, Linneus and Sagar, and includes several of their
 genera in his own definition, which runs in more general terms as
 follows: " pyrexy  severe;  pain of the head; readness of the face
 and eyes; intolerance of light and sound ;  watchfulness; fierce de-
 lirium or typhomania."
   There is so much correctness in this remark of Dr. Cullen's, not-
 withstanding the error of his arrangement, that the present author
 yielded to  it  in the first  edition  of his  Nosology, and introduced
 cephalitis, not indeed as a naked genus without a specific character,
 but  as a single species without enucleating  its varieties; or, in other
 words, without  treating of deep-seated inflammation  constituting
 acute  internal dropsy of the brain, separately from  inflammation of
 the  head generally. It may,  perhaps,  be  doubted, whether acute
 dropsy of the brain ought to be regarded as an idiopathic inflamma-
 tion at all, and consequently whether the present is the proper place
 for it: hut the reasons which will immediately be advanced will, I
 trust, settle this point completely.  And, as, upon a  closer attention
 to the  subject, notwithstanding Dr. Cullen's  remark, I am induced
 to think that there are cases in which parenchymatous or deep-seat-
 ed inflammation may be distinguished from meningic, I have so far
 deviated from the first arrangement as to give these  distinctions un-
 der  the form of  the two preceding varieties.
  I  admit nevertheless, with Dr. Cullen, that there are no symp-
 toms capable at all times of distinguishing, with certainty, inflamma-
 tion  of the substance of the brain from inflammation of its meninges;
 and  only contend that the distinction may be drawn  in certain cases
 in which the disease is  simple, and the characters  strong and un-
 mixed; and strikingly indicative of membraneous or parenchyma-
 tous inflammation, according  to  the general rules  just laid down
 upon 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
 these nosologists that describe but a single species, or genus of this
 disease, as it has been often though incorrectly denominated, as Vo-
 gel,  Cullen, and  Parr, lean chiefly to the meningic variety, and de-
fine it by characters of great vehemence or acuteness, so as in reali-
 ty to limit themselves to this variety 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 commonly seated, in the substance of the brain itself than
in its membranes, they have all been dissatisfied with their respec 
GE. VII—Sr\ 1.]     SANGUINEOUS FUNCTION.
217
tive definitions;  and instead of enlarging or modifying their terms
to meet the distinctive phaenomena as  they vary according to the
scat of the disease, have endeavoured  to apologize for their own
inaccuracy, by representing these phaenomena as irreducible and
anomalous.
  The first  variety, therefore, exists in the judgment, and even in
the description of all writers, who, where they have not entered
into more minute subdivisions, have given it as the general charac-
ter of the complaint.
  The existence of the second variety, or in other words, the pro-
priety of regarding what has  hitherto  been denominated acute or
internal hydrocephalus as a variety of cephalitis, requires to be ex-
amined somewhat more at length.
  The absurdity of the usual arrangement of internal hydrocepha-
lus, and of contemplating it as belonging to the ordinary family of
dropsies, with which it has scarcely a common symptom, has long
been felt by pathologists, and is directly noticed both by Sauvages
and Cullen.   But the question is, if we remove it from its usual si-
tuation, where are we to place it?  if we do not regard it as a drop-
sy, in  what light  are we to contemplate it at all? and how are we
to regulate our treatment of it ?  The professor of Montpellier tells
us that, according to its symptoms, it is to be ranked in the coma-
tose, spasmodic, or some other tribe of diseases ; distinctly import-
ing that, in his own opinion, he could not  refer it to any single divi-
sion in 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 below puberty, first with lassitude, feverishness, (febriculi,)
  Vol. II.—E e 
21S                      HJiMATlCA.           [CL. lit.—OR. H

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  great body of pathologists
have been dissatisfied with it, and  have correctly carried internal
hydrocephalus over to the class of pyrexies,  and regarded it as a
fever or an inflammation.  Thus in Dr. Macbride's  table it occurs
as a nervous fever, under the title of febris continua, nervosa, hy-
drocephalica : and more simply under that of febris hydrocephalica,
in Professor Daniel's edition of Sauvages; while Dr. Quin of Dub-
lin, Dr. Withering, Dr. Rush, Professor Martini, and a host of other
writers of authority, have contemplated and treated it as an inflam-
mation,—an inflammation of the brain,—and consequently a cepha-
litis; the  fever being  regarded as a mild and somewhat irregular
cauma,  and  the effusion  into the ventricles of the brain as a mere
effect of the inflammation.
   This  is not the only instance, indeed, in which cauma assumes a
mild character.  In various other species of empresma it is often
found to do  the same, of  which  the reader  will find an interesting
example under the species laryngitis, a few pages further  on:  and
of which every practitioner is meeting with  daily instances in pneu-
monitis, and especially in inflammation  of the parenchyma of the
lungs producing suppuration.   The general organ of the brain,
however, seems to have less irritability than almost every other or-
gan when in a state of health, and we often find it to be little irrita-
ble in a state of lesion ; since nothing is more common than for a bul-
let, or the broken point of a knife, sword,  or other weapon, to be
forcibly driven into it, and buried there for weeks, months, or years,*
in one  instance eleven years,t not only  withouudanger, 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
cbnfirming  this view by  a variety of strongly  marked and well
selected cases. And I am glad to avail myself of Dr.  Porter's autho-
rity in following up this second variety of cephalitis, into a distinct
and extended illustration.
* Gooch's Cases.  Hoegg. Diss. Observ. Medico-chir. Jen. 1762.
f Majanet, Journ. de Med. torn. XLI. 65.  In. torn. XX. 543. 
GE. VII.—SP. I]    SANGUINEOUS FUNCTION.
219
   In few words both varieties not only evince symptoms of inflam-
 mation during the progress of the disease, but anatomical proofs of
 the same upon dissection after the disease  has terminated fatally;
 in the meningic subdivision the complaint commencing in and being
 ordinarily confined to the meninges or membranes of the brain, the
 blood-vessels chiefly affected with inflammatory action being the
 meningic branches of the external carotid;  and in the deep-seated
 subdivision the complaint commencing in and being ordinarily con-
 fined to the posterior part of the brain, the blood-vessels chiefly af-
 fected  being minute branches of the basilary artery. It is neverthe-
 less possible, and appears often to become a fact, from the anastomo-
 ses that are  occasionally found  between different arteries of the
 brain, from the continuous spread of morbid  action from neighbour-
 ing sympathy, or from some unknown cause, that either variety may
 pass still deeper or wider into the substance  of the brain, and make
 an approach towards the other; and hence, the mixt, anomalous, and
 even contradictory symptoms, by which the specific character is
 sometimes distinguished; a striking example of which, but too long
 to be quoted, is to be found in the Edinburgh Medical Commenta-
 ries.*
  "In  three cases," says Dr.  Sagar, "I have found suppuration of
 the brain after death; in each of  which the patient during the pro-
 gress of the disease breathed sonorously but without stertor.f Whe<<
 ther in the case of effusion between the membranes, the fluid be
 confined, where the  disease commences in the meninges, to the
 space between the dura-mater and  the arachnoid tunic, and where
 it commences in a contiguous part of the brain, to that between the
 arachnoid tunic and the pia mater, as asserted by Dr. Porter, I have
 not been able to determine."
  We  may hence explain why the symptoms of irritation and op-
 pression should so much vary as  we find they do in different cases;
 why there is sometimes no delirium and at other times a considera-
 ble degree; why the  delirium is sometimes furious and impetuous,
 constituting the delirium ferox of medical writers; why in other in-
 stances it is mute or muttering, designated by the  phrase delirium
 mite; and  why there should  occasionally occur examples of that
 comatose or heavy stupor to  which the Greeks  gave the  name of
 typhomania;  as also  why the  pain  and pyrectic symptoms should
 vary from  great acuteness  to a  mere disquieting  head-ache  and
 slight increased action.
  Phrensy is not often found  as an idiopathic complaint, at least in
 this country; though it is a frequent attendant upon other diseases,
 as synochus, worms, various exanthems, trichoma, hydrophobia, in-
juries of the brain, and severe grief.   It sometimes makes a near
approach to mania, but is easily distinguished by the nature of the
exciting cause, where this can be  ascertained, the abruptness of the
• Vol. IX. p. 164.
f Syst. Morb. Sympt. Cl. XI. Ord. III. Gen. xii. 
220
HAEMATIC A
[CL. HI.—OR. II.
attack, and the violence of the fever; added to which there is  in
phrensy, for the most part, though not always, a hurry and confusion
of the mental powers, a weakness and unsteadiness of mind, which
is rarelyor perhaps never to be met with  in  genuine  mania.  It
sometimes, however, runs into  mania, of which Stoll has given a
singular instance in a chronic case that continued for nine weeks
before  it assumed this change.*
   The remote causes are those of inflammation in general applied
to the organ- affected; such as sudden exposure to cold after great
heat; cold liquors incautiously drunk in the  same state; inebria*
lion, and especially from spirits ; exposure of the naked head to the
rays of a  vertical sun; violent passions of the mind; obstructed
menstruation ; and various kinds of poison.
   The cure of phrensy must be  attempted  in the same manner as
that of inflammation in general, or rather as the cure of  inflamma-
tion by resolution ; for resolution is the only means by which a cure
can be effected in this case.   Copious and repeated bleedings must
here therefore hold the  first place; and the nearer the blood is
drawn  from the affected organ the better chance it gives us of suc-
cess.  The temporal arteries and the jugular veins have hence been
recommended as the most effectual vessels to open ; but for various
reasons it is better to begin  with drawing blood liberally from the
arm, and afterwards by a free application of leeches to the temples.
The head should be shaven as soon as possible, and kept moist with
napkins wrapped round it dipped in cold vinegar, or  equal parts of
water and  the neutralized solution of ammonia; or, which is still
better, with ice-water;  all of which is preferable to blistering, which
is too apt to increase the morbid excitement;  and has the authority
of Hippocrates, who was in  the habit of applying cold epithems,
not only in inflammation of the  brain, but  even of the  abdominal
viscera.t   The  bowels should be thoroughly evacuated, and  even
stimulated at first by calomel alone or mixed with jalap, and after-
wards  kept open by cooling saline  aperients :  and nitre should be
given  in moderate quantities, repeated as often as the stomach will
bear;  which is often considerably assisted  by the tincture or  infu-
sion of digitalis.  The chamber should be cool and  airy; and no
more light be admitted than  the eyes can endure  without inconve-
nience.
   I have said that furious delirium, though generally laid down as
 a pathognomic of this variety of cephalitis, does not always occur;
and in a very strongly marked case in which I was consulted about
 three years ago, the mental powers were not much interfered  with.
 The patient was a lady of delicate habit, about thirty years old, who
 had caught cold by lying on an Indian  mat, spread on the lawn, in
 the midst of  a hot July.  The first symptoms were those of inflatn-
• Rat. Med. Sect. HI. p. 179.
■{• CI«g< Not/sw, p. 448. 
GE. VD.—SP. I.]     SANGUINEOUS FUNCTION.               221

matory  fever,  with an  acute pain in the head, which was not so
much attended to as it ought to have been.   I did not see her till
the second or third day of the attack, when she had been bled only
once, and that not very freely;  though the bowels had been freely
evacuated.  At this time the pain in the head was intense, with an
intolerable acuteness of hearing and sight, insomuch that the slight-
est light and sound, even the humming of a fly, were insupportable.
The face was flushed: the eyes swollen,  the head externally hot
all over as a furnace; whilst a violent throbbing or thumping pul-
sated within.  Free bleeding now, though repeated till the system
was weakened to its lowest ebb, produced little or no relief.   The
nair 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, le-
monade, grapes, and other cooling medicines, were chiefly depended
upon.
   As the weakness increased  the mind wandered a little for a few
minutes at a time, but never totally, nor without being easily recall-
ed ; but every attempt to sleep produced, at this period, the most
horrible ideas, accompanied with cold sweat and syncope on waking;
even though  the miserable  dozing had continued only for a few
minutes.  This distressing "state was relieved by ten grains of the
compound ipecacuan powder, which produced quiet sleep for seve-
ral hours.  But opiates had hitherto uniformly disagreed  with the
patient's constitution, and did the same now, throwing out a rash
over the entire surface of the body that produced an intolerable
itching, and was accompanied with a deadly nausea at the stomach ;
,and this too, after the first  dose, without any relief to the state of
the head.  They were tried in various forms,but had  constantly the
same effect; and we were obliged to relinquish it.  Hyoscyamus
and other narcotics were substituted, but proved of no service.
 Camphor, taken  freely both in pills and solution, allayed in some
degree the horror of the  sleeping ideas ; and as the fever began to
 subside, cascarilla, with sulphuric acid, appeared also to be servicea-
 ble ; 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
HiEMATlCA.
[GL. HI.—OR. U.
  we have a clear proof also that the stimulus of the will answered
  the same purpose at this period.  This distressing affeclion 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 symptoms in common with chronic or idiopathic hy-
 drops cerebri, and that such a generalization has been a cause not
 only of much confusion in nosology, but of much mischief in prac-
 tice.
   This disease is  sometimes found in adults, but mostly in young
 subjects,  and chiefly from early infancy to seven years of age, par-
 ticularly in  those of a fair complexion.   After seven years the dis-
 ease is comparatively rare.
   The symptoms commence obscurely, and are those of irritation
 produced by worms:  as irregularity, and especially costiveness in
 the  bowels; listlessness; impatience; knitting the brows  into  a
 frown; heaviness of the head, which  organ the patient is always
 desirous of reposing in a chair or some other place; irregular
 fever; and, occasionally, violent and deep-seated pain in the senso-
 ry shooting from temple to temple,  or across the forehead; fre-
 quently accompanied  with sickness.    The pulse is irregularly
 quick; the sleep unquiet, and interrupted by screams;  and the eye
 has a look peculiarly oblique or squinting.   These three last symp-
 toms are  usually regarded as pathognomic.   The eye, however,
 instead of taking an obliquedirection, 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 th* symptoms are apt to assume deceitfully for a few hours,
perhaps a day or two, a milder character; but the pulse evinces less
power, stupor supervenes,  occasional convulsions, more or less
general, follow, and death very speedily closes the scene.
  I have thus given a brief sketch of the symptoms that principally
mark the  process of  this disease in all their  versatility; and it is
this versatility that has  produced the chief differences of opinion
that have been entertained concerning it, to which we have already
adverted. 
SANGUINEOUS FUNCTION.             22S
  The first symptoms are unquestionably rather those of  irritation
than of compression, as is obvious from their resemblance to those
of invermination.  The venous  system  in children, indeed,  and
especially the veins of the head, are not disposed to plethora, which
is rather a characteristic feature of advanced years; nor does the
small quantity of water which is often found in the ventricles seem
adequate to the violence of the effect;  and  we have  hence  very
strong grounds for supposing that the collection of water is only a
secondary disease, dependent upon some previous idiopathic affec-
tion in some part of the brain; and that affection, as Dr. Rush has
long ago very ably shown, an  inflammation.   It has  indeed been
observed, in opposition to this opinion, that acute hydrocephalus is
less frequently to be met with  in strong and vigorous, than in weak
and sickly children, dropsy being here, as in other species, far more
commonly an effect of debility ; whilst it is in strong and vigorous
 children alone that we have reason to expect inflammatory action
 in the brain, as in any other organ.  Bleeding it is admitted has been
 serviceable at times, but we are told that it  has often been unproduc-
 tive of any  benefit whatever;  and that it is possible to account fox-
 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 characterized.
    The mode of practice,  in  consequence of this discrepancy  ol
  oninion, has been extremely undecided; whilst many practitioners
  are so despondent as to fear that every  plan is equally  unavailing.
  It has fallen to the author's lot, however, to  see  several patients
  recover both in infancy and verging towards  adult age, who had
  all the characteristics of the disease, and were unquestionably labour-

  111 Contemplating it as a variety  of cephalitis, he  has uniformly
  nursued the  general plan recommended under the  preceding vari-
  ety, and to this practice he can only ascribe  whatever degree  of
  success he has been  fortunate enough to meet with.
    Blood should be drawn freely from the nape of the neck by cup-
  nine or leeches : the head should be shaven, and napkins dipped in
  ice water, or vinegar and water, be applied to the posterior part of it,
  ard be changed every hour or half hour.  The bowels should be free-
  ly ourged with  calomel, or calomel and  jalap: an easy diapnoe
  should  if  possible,  be excited, and maintained on the skin ;  the
  clumber should be  large and well  ventilated; and when it  may
  b ■ '■:   ♦ »c -nmalat- the head, epithems of neu.ral.zcd  ammonia
         ' \xi preferred to blistering.  The  value of digitalis is..doubt-
          -  used eruv it has seemed serviceable, but it should  be
                   ^nd stage  of the  disease.  In later life than in-
- Dt
   :. US 
 224                     HJEMAT1CA.            CL. IU.—OR. 11.

 fancy,  where it  has  been necessary to draw  blood  repeatedly,
 I  have occasionally prescribed opening the temporal artery with
 great success; for a small quantity, as six or eight ounces of blood,
 drawn in this way, will  often answer  the purpose of double or
 treble the quantity abstracted from the  arm.  In  a young lady of
 nineteen, labouring under very prominent symptoms of this disease,
 I found the violent and deep-seated pain in the head cease instant-
 ly ; and the pulse sink from seventy to forty-four,  as soon as a tea-
 cup-full of blood only was taken in this manner.
   Mercury employed  both externally  and internally, in a quantity
 sufficient to excite a pytalism, 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, antf seven
 scruples of strong  mercurial ointment had been  rubbed into the
 legs.* Dr. Dobson of Liverpool employed quick-silver in the same
 double plan, and asserts that he found it  equally useful, and most
 strikingly so in the following case. Four children in the same family
 had evinced this disorder in succession; three had fallen victims to
 it under a different treatment: one between three and four years old,
 was subjected to the mercurial plan of calomel and inunction.  In
forty-eight hours  a ptyalismwas excited, the symptoms abated, and
the child recovered.t
  In adults the ordinary proportion is ten grains of calomel and a
 drachm of strong mercurial ointment every night.  Under this treat-
ment various cases of success are recorded in the Edinburgh Medi-
cal Journal.
                       SPECIES II.

                 EMPRESMA OTITIS.

                         22ar~acue.

severe pain in the ear ; tenderness upon pressure; deafness
                   OR CONFUSION of sounds.

This is a distressing rather than a dangerous disease; but the fever
is sometimes violent, and delirium  has occasionally been a conse-
quence.   It is often produced by cold, and hence frequently a symp-
• Edin. Med. Com. Vol. VI. p. 224.
fid. 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, affecting the membranes and surface of the organ, and
coating them with coagulable lymph, pus, or both ;  while even the
temporal bone of the affected side has become carious.  A case of
this last kind is related by Dr. Powell in the Medical Transactions.
The patient was a young gentleman of sixteen,  who  had been at-
tacked with otitis once or twice before.  The pain was intense, but
the pulse never exceeded seventy-two: yet the disease proved fatal.
The intellect was at no time disturbed.§
  The general remedies for inflammation  are here to be  resorted
to ; and particularly warm, narcotic fomentations.  Blisters behind
the ear have often afforded relief; and for  the same reason stimu-
lant errhines and sialagogues:  which, by evacuating the  mucous
follicles of the Schneiderian membrane, and the salivary glands,
produce an influence on all  the neighbouring parts, and often on
the whole of the vessels of the head.  And hence head-aches, oph-
thalmies, and pains in the ear, are in many instances equally reliev-
ed by these applications, and  were  often employed by Dr. Cullen
for this purpose.||
  When worms or the larves of insects are the irritating cause, a
few drops of oil of almonds introduced into the ear will readily suf-
focate them.
                       SPECIES  III.


              EMPRESMA PAROTITIS.




PAINFUL UNSUPPURATIVE TUMOUR OF THE PAROTID GLANDS, OFTEN EXr
  TENDING TO THE MAXILLARY :  CONSPICUOUS EXTERNALLY ; OFTEN
  ACCOMPANIED WITH  SWELLING OF THE TESTES  IN MALES, ANp OF
  THE BREASTS IN FEMALES.

The parotid glands are subject to a troublesome, and sometimes a

  • Hagendom, Cent. I. Obs. 64.
  | Fabric. Hildan. Cent. HI. Obs. 4.
  t Stalpart Van der Wiel.  Maget  Journ. de Med. torn. LXIV. Moehring,
Obs. 21. Samml. Medinischen Wahrnehmungen, B. VIII. p. 37.
  § Vol. V. Art. xvi. p. 212.
  || Mat. Med. Vol. II. p. 436. 442.
  Vol. II.—F f 
226
HA.MATIUA.
[CL. III.—OR. If.
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 branks.
  The tumour, though sometimes confined to one side of the neck,
more usually appears on  both: it is at first moveable,  but  soon
becomes diffused to a considerable  extent.  It increases till the
fourth day, and often involves the maxillary glands in the inflamma-
tion ; is evidently contagious, and often epidemic. After the fourth
day it gradually  declines;  and for the most part there  is but  little
pyrexy, or need  for medical aid; avoiding cold, and  a brisk purga-
tive or two being all that is called for.  The sympathetic action of
the testes and the mammae is most conspicuous towards the decline
of the inflammation.   And, in many instances, it  is by no means an
unfavourable sign ;  for it  has been occasionally found that where
the sympathy has not been manifested, or the glandular swelling has
been  suddenly repelled, the symptomatic fever has been greatly
exacerbated, delirium  has ensued, and even death has closed the
scene.  Where  there is any danger of such a result,  the swelling
should if possible be brought back or sustained  by stimulant cata-
plasms or blisters.   Dr. Hamilton has in several cases observed this
sympathetic influence  operating alternately: and mentions more
than one instance in which after a very considerable enlargement
of the testicle, upon the cessation of the disease,  this organ entirely
wasted away, insomuch that the  tunica vaginalis  became an empty
bag.*
  In advanced life parotitis is sometimes apt to  run into a chronic
form, accompanied with very mischievous symptoms; in which state
it is denominated a malignant parotid.  This is more especially apt
to take place in females when menstruation is on the point of ceas-
ing, and the general action of the system labours under some dis-
turbance.  The 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 dege-
nerating 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]    SANGUINEOUS FUNCTION.              227


                       SPECIES  IV.

            EMPRESMA  PARISTHMITIS.

                          <&ufnsB.

 REDNESS AND SWELLING OF THE FAUCES;  WITH PAINFUL AND IMPED-
                       ED DEGLUTITION.

 This is the squinsy, or squinancy of our old writers;  the cynanche
 or angina of medical books.  Paristhmia from vxpx and te-9fM$, lite-
 rally morbus faucium or throat-affection,  is the term employed by
 Hippocrates, and is only varied to paristhmitis, in the present sys-
 tem,  in consonance with the general termination of all the species
 belonging 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 varie-
 ties:  and hence we meet  with cynanche,  synanche,  and parasy-
 nanche;  the common signification of all which is angina  or stran-
 gulation, while the prefixes cy- sy- and parasy- are of doubtful
 meaning, as I have further observed in the preliminary dissertation
 to the Nosology.  Aetius attempted to justify cynanche, but Caelius
 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 paristhmitis tonsillaris of  the system before us ; their parasy-
 nanche  the quinsy of the pharynx, paristhmitis  pharyngea; and
 their  cynanche, croup, or p. trachealis.
  Quinsy presents itself to us under three varieties ; the  common
 inflammatory sore-throat;  the ulcerated or malignant; and the sore-
 throat that peculiarly attacks the pharynx.

 x Tonsillaris.                  Swelling of  the  mucous mem-
  Common Quinsy.              brane of the fauces,  and  espe-
  Inflammatory sore-throat.       cially of the tonsils ;  redness
                                florid ; fever a cauma.
 • Maligna.                    Redness crimson ;  with ulcera-
  Ulcerated; or                 tions  covered with  mucous
  Malignant sore-throat.           and spreading sloughs, of an
                                 ash or whitish  hue:  fever a
                                 typhus. Frequently epidemic;
                                 generally contagious.  Found
                                 often as a  symptom in rosalia,
                                 or scarlet fever.
yPharyngSa                    Redness  florid,  and especially 
228
H—MATICA.
[CL. 1U.—OH. U.
  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, greatly impeded : and the speech,  and sometimes even
the respiration rendered highly troublesome:  the mucus  is excre-
ted sparingly, and consequently there is a considerable clamminess
in the mouth ; and the pain sometimes spreads to the ears.  The
disease  is never contagious, and  though violent while it  lasts,  is
comparatively of short duration.   It terminates  by resolution, or
suppuration ;  hardly ever by gangrene; though a few sloughy spots
sometimes appear upon the fauces.
  The usual cause is cold ;  and it is hence found most frequently in
spring and autumn, when vicissitudes of heat and cold  are  most
common.  It is supposed  to affect particularly the young and the
sanguine—but, in my own practice, it has occurred as often at other
ages and in other temperaments.   When it has  been re-produced
several times within short intervals of each other, it is apt to estab-
lish a peculiar diathesis or habit, so as to be excited readily and by
very slight occasional causes.
  If attacked by a medical process early, much benefit has  been
derived  from astringent and acid  gargles, and vapours inhaled by
any simple machine  for this purpose.   Blisters  to the throat or
behind the ears, ought also to form a part of the curative plan ; and
if bleeding be had recourse to, it should be by scarification or leeches
applied  to the tonsils  or fauces.  An early, use of leeches I have
often found highly successful.  Cooling  purgatives, and a low  re-
gimen should also enter into the general plan of treatment. If sup-
puration cannot hereby be prevented, the better way will be  to
expedite this termination by the steam of warm water, or water im-
pregnated with the leaves of rosemary or chamomile : and when the
fluctuation is clear to the touch, if the abscess  do not of its own ac-
cord break readily, it  ought by all means  to  be  opened with the
lancet.
   In a few instances  the suppuration has pointed and broken ex-
ternally, and  the termination has  been favourable.*  And occa-
sionally, from the extent and violence of the inflammation, there
has been so much danger of suffocation, that it has been found ne-
cessary  to make an opening into the trachea :f which has been done
sometimes as high as the larynx, and sometimes considerably lower;
and under both kinds of operation the patient has recovered.}
   In the malignant or second variety, the  inflammation passes
• Schenck. Lib. II. Obs. 36.
t Ballonius, I. p. 182.  Fernire, Journ. de Med. torn. LXII.
t Fienus, Chir. Tract. IV. V. C. 1.  Musgrave, Phil. Trans. N. 258. 
GE. VH.—SP. IV.]    SANGUINEOUS FUNCTION.
229
at once into the ulcerative stage; and is consequently characterized
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  atmo-
sphere,  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; or with a strong de-
• Pract. of Phys. Part I. Book III. Ch. IV. Sect. DCLJ. 
230
HiEMATICA.
[CL. III.—OR. H.
 coction of bark, or catechu, which is better, very sharply acidulated
 with minerals 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,f and the mineral acids.
 The stimulus of mezereon is les^ 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 pharmacopoeias by the name of per-
 sicaria  urens, which, in many instances, answers very effectually.
 And, in conjunction with these, camphor or ammonia has often been
found beneficial when externally applied in the form of a liniment.\
 Bark and wine, indeed, should  be taken jointly, and in as large a
quantity as the system will bear.  Even sleep is less necessary than
both these; nor should the patient be suffered to rest for a period
of three hours at a  time, without fresh doses of both,  though we
wake him for the purpose.   Time, indeed, is here every  thing :  if
we make no progress in the first thirty-six hours we may tremble
for the event; if we  lose ground in twenty-four hours, we shall have
to hope against hope.  Women, unaccustomed to wine, have taken
it successfully under this disease, in the proportion of  two  bottles
a-day, far 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 inffammation, 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  bleed-
ing and  brisk purgatives.
* Journ. de Med. Nov. 1789.
f Collin. Med. Comment. II. 27.  Stephen, Med. Comment. Edin. V.
* Uumsey, Lond. Med. Journ. X.—Medicus, Beobacbtungen H. 505. 
GE. VII.—OR. V.]    SANGUINEOUS FUNCTION.              231



                        SPECIES V.

             EMPRESMA LARYNGITIS.

              Xuflammatum of the  3Lavwv>

TAIN ABOUT THE L\RYNXJ EPIGLOTTIS SWOLLEN AND ERECT; BREATH-
   ING SHRILL AND SUFFOCATIVE; GREAT ANXIETY; DEGLUTITION IM-
   PEDED ; FEVER A CAUMA.

It  is doubtful whether this severe and dangerous complaint has
ever been described till of late years. It seems to have been known
to Dr. Mead, whose general account coincides with a disease notic-
ed by Hippocrates.  It is minutely and  accurately detailed by Dr.
Home, in his Principia; and is the subject of several excellent pa-
pers in the Transactions of the Medico-Chirurgical Society, parti-
cularly 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.t
   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 protrud-
ing, 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  deglution, 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.
f Obs. 29. ex Trincavellio, lib. II. 
232
HjEMATICA.
[CL. III.—OR.IL*.
 diseases differ, moreover, in their proximate causes as considera-
 bly as in their symptoms.   Laryngitis consists in a suppurative in-
 flammation of the membranes of the larynx, extending backward to
 the membrane common to itself, and the oesophagus, between which
 pus is often found lodged : while croup or bronchitis is a peculiar in-
 flammation of the treachea, 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 oft* the inflammation by the most active means. For this pur-
 pose eighteen ounce's of blood should  be instantly drawn from the
 arm, and eight  or ten from the throat by leeches ; and the bowels
 should be thoroughly purged by calomel and jalap, or some other
 active cathartic.  In connexion with this process many writers ad-
 vise the application of a blister, and the use of relaxant inhalations.
 But, in preference to both, I would recommend gargles of ice-water
 acidulated, and epithems of pounded ice applied externally.  If this
 plan do not at once succeed, no time is to be lost, and bronchotomy
 must be had recourse to.  But whether the opening should be made
 in the larynx, or below it, must be left to the judgment of the sur-
 geon to determine.
  In a few instances, however, this disease seems to commence with
 comparatively little violence;  and to run  easily into a chronic form :
 a case of which kind is described by Mr. Wood in the Edinburgh
 Medical and Physical Journal.  The child, a female, was ten years
 old when she was attacked.   The symptoms for  the first three or
 four days 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 VII.—SP. VI.]   SANGUINEOUS FUNCTION.               233


                       SPECIES VI.

             EMPRESMA BRONCHITIS.

                          (Erouji,

BREATHING PERMANENTLY LABORIOUS AND SUFFOCATIVE ; SHORT, DRY
   COUGH ; EXPECTORATION CONCRETE AND MEMBRANOUS ; FEVER A
   CAUMA.

The writers on croup  have given but one form of  it, except what
has been  erroneously called spasmodic croup, a disease of a different
kind, which has already been described under the name of laryngis-
mus  stridulus.  Properly speaking, however, there are two forms,
an acute  and chronic, under which the present species shows itself,
and which may thus be distinguished as varieties:

«  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.
3 Chronica.         Sense of suffocation obtuse and heavy; chiefly
  Chronic croup.        seated in the chest; cough severe, but in-
  Bronchial polypus.    terminating; extending to some weeks or
                       months.

  The disease, in both varieties, usually commences with the com-
mon symptoms of a cough or catarrh ; but essentially consists in a
peculiar inflammation that spreads through different parts or even
the whole range of the windpipe,  from the larynx to the minutest
ramifications of the bronchiae. 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 treachea,
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 wojuld  be better, perhaps,  to regard  this last af-
fection as a variety of catarrh, than to treat of it as a distinct species
under a distinct name.
   The first variety,importing the common or acute group, the suf-
focatio stridula of Dr. Home, who has the merit of having earliest
called the attention of medical practitioners  to it as a distinct dis-
ease, though it extends thus widely, usually commences in the larger
parts of  the tube; during which a peculiar effusion  is secreted,
that  readily assumes a membranous form, and lines,  not only the
trachea above its devarication, but also its minutest branches, though
   Vol. II.—G g 
■:-j4
HJEMATICA
[Ci.. in—or. u
the larger parts of the tube are first affected.  When chemically
examined, the secretion appears to consist chiefly, if not entirely, of
the gluten, or coagulable lymph of the blood, diluted with its sero-
sity, and copiously combined with that  peculiar substance of the
blood, detected by the labours of modern chemistry, which, from its
essential tendency to concrete into a fibrous, and even a membra-
nous texture, has received the name of fibrin.
  By what means the mucous secernents throw forth  this peculiar
effusion on this peculiar occasion we know not.  It  is said by some
writers to be secreted on  no other occasion, and by no other organ;
but this is unquestionably a mistake.   There are few practitioners,
perhaps, of accurate observation, who have  not found it discharged
at times from  the intestinal canal; of which I have already  given
examples under diarrhea tubularis ; in which, as in croup, there is
an inflammatory affection of the  morbid organ, and  a spasmodic
constriction of the passage.
  In reality the effusion, distinct from the inflammation that gives
rise to it, is not essentially different in its principles from what oc-
curs in  genuine polypus, or that of the nostrils, and those polypus
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 anginapolyposa :* 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 an existence or not  have
been definitively noticed  or described by medical writers: for  Dr.
Cullen appears to be perfectly correct in referring to Dr. Home as
the first person who has given any distinct account  of  it.f
  It is also not a little singular that children should be chiefly sub-
ject to its attack, at whose age fibrin is not peculiarly abundant, and
whose blood contains comparatively but a small proportion of azote,
which in fibrin  is so large a constituent.  These are among the ma-
ny  curiosities which the prying eye of physiology has  yet to follow
up: and much has it to accomplish before it will be able to explain
them.
  Dr. Cullen asserts that acute  croup seldom attacks infants till af-
ter  they have been weaned ; and that there  is no  instance of its oc-
curring in children above twelve years of age.  As a  general rule
• De Anguini polyposa. Auctore Christ. Fred. Michaelis. 12mo. Argentor.
79.
f De Suffbcatione stridula. 
GE. VH.—SP. VI.]    SANGUINEOUS FUNCTION.              2S5

this remark holds, but the disorder has been found occasionally in
persons considerably above twelve years of age.  Those who have
once had it are more susceptible of it than before; though the sus-
ceptibility  gradually wears off as  they  grow older.   It is found
equally in midland regions and on the coast: but perhaps more fre-
quently in low, marshy grounds, than in drier  uplands.  There is
no unequivocal instance of its being contagious, though it seems to
have been occasionally epidemic.
   It commences usually with a slight cough, 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
difficulty of breathing, and a sense of strangling in the fauces,  the
patient 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 mem -
• Pract. of Phys. CCCXXIV. 
236
HJEMAT1CA.
[CL. Hi.—OK. 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 otner 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.
   The cure demands a prompt and active attention ;  and must de-
pend not so much upon searching into and correcting the remote
cause, or even  counteracting the spasm, as in counteracting and
removing the membraneous  secretion,  which  is every moment  in
danger  of producing  suffocation; and especially in children,  in
whom the natural  aperture of the glottis is much smaller  in  pro-
portion than in  adolescents;  and occasionally not more  than a line
and a half in breadth.
   There is in the patient  a perpetual effort to remove this solid se-
cretion by coughing; but the cough is for the  most part dry and in-
effectual, and nothing more than a little flaky mucus is excreted.
Very copious bleeding*  at  the commencement of the attack, by
breaking abruptly upon the inflammatory action, has sometimes car-
ried off the disease at once.  This M.  Fieliz recommends from the
jugular veins,t and M. Ghisi by tropical scarifications; but leeches
will usually be  found  to  answer best  in infancy.  Emetics have
afterwards been  tried, but with doubtful success: sinapisms:}: and
blisters§ with as little.   The  inhalation of warm vapour, recom-
mended  by Dr. Home, can rarely be practised from the extreme
restlessness of the little patient; and the remedy principally relied
upon in the present day,  and  which certainly seems in many in-
stances to have  operated like a charm, is large and repeated doses of
calomel; 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 membraneous 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.y But this advice  is  given with more  courage than judg-
ment.  Whenever performed it should be after every other remedy
has failed, and not before  any other has been attempted.
• Michaelis. Richter's Chir. Bibl. v. B. p. 739.
f Fieliz. Richter's Chir. Bibl. VIII. B. p. 531.
* Fieliz, 1. c.
§ Inquiry into the nature, &c. of the Croup.
II De Angina polyposa, &c. ut supra. 
 GE.Vn.—SP.VI.]    SANGUINEOUS FUNCTION.               237

   Under the genus laryngismus belonging to the second order of
 the preceding class, I have observed that  the spasmodic affection
 there described, from its inducing  a  sense  of suffocation, and pos-
 sessing various other symptoms resembling  those of croup, has often
 been mistaken for this last complaint, and been denominated spas-
 modic croup; though without the pathognomic sign of a membrane-
 like exudation, and for the most part without any inflammation what-
 ever. 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  alarm-
 ing course till  it destroys the  patient or yields to the  means made
 use of.    During the action of the spasm, however, there is a con-
 siderable hoarseness and shrillness in the voice, and, from the strug-
 gle, a profuse perspiration 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  inoculated  by radicles  or radiating  vessels, as to produce
 a fatal hemorrhage  on their being thrown up with violence, has
 been noticed from a  very early period in the history of medicine
 to the present day.  Bartholine, Tulpius, Ruysch, Gretz, and Mor-
 gagni, have all been appealed to as giving  examples of this affec-
 tion; and it is  very possible that even Hippocrates may allude  to
something of the kind in the case of Pherecydes who, he tells us,
was accustomed to bring  up from  his lungs in a fit of  coughing,
yxXxx-Tuhx, "white milky concretions;" and at length  before he
died oiov ex. jtM>|jjs f^vxTjTX, |yv£—»;*«Tfl6, Xevx.u ^Xiy/Mtrt 7reote%oftevx," firm
mucus-like excrescences, surrounded with  white phlegm."*  But
 the complaint does not seem to have  been distinctly described, till
Dr. Warren's  history  of  it in  the Transactions of the  College.f
The case by which he chiefly  illustrates  it,  and which is here
chiefly alluded to,  is that of a  young lady eight years of age,  of a
strumous habit, who was suddenly  attacked with a  difficulty  of
breathing, attended with a short, dry, and almost incessant cough;
but without any pain in the side or chest.  The symptoms diminish-
ed in the  ensuing  night,  and the complaint appears  to have been
productive of little inconvenience for six weeks; when it returned

               • De Morb. Popular. lib. VII. Sect. xli.
               t Vol. I. Art. XVI. 
MS
HAEMATIC A.
[CL. III.—OK. 11.
 with additional  seventy, with costive  bowels, a white but  moist
 tongue, and a pulse too quick to be counted. Bleeding, purgatives,
 and the oxymel of squills relieved her, but the breathing was still
 laborious; she had wasting night sweats, and the pulse beat from a
 hundred  to  a  hundred and twenty strokes  in  a  minute for the
 ensuing twelve days, at the close of which period, 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 op-
 pression on the lungs returned irregularly after intervals of five,
 eight, ten, or twenty days, always followed and always relieved by
 an expuition of the same concrete  material; till  at the close of  a
 twelvemonth from the first attack, the patient complained of a pain
 in the right heel, an abscess formed  there, and the os calcis was
 found carious.   From this time the bronchial affection  ceased, the
 breathing was perfectly free, and no more concretion  was at any
 time thrown up.
  Dr. Warren conceived this concrete substance to have been an
 inspissated matter secreted by the mucous glands  of the baronchial
 vessels.   But the existence of fibrin, as a constituent  part of the
 blood, was unknown at the period in  which he wrote;  and his
 plates and description of the membranous matter expectorated  show
 evidently, that, like that discharged in croup, and often from the
 intestinal canal,  it was  composed of this formative  element inter-
 mixed with gluten, secreted in layers, and affecting a tubular struc-
 ture.  " Some of these polypi" says he, " are of a much firmer
 texture than others, and bear shaking in water without  breaking to
 pieces.  Others are so tender that  a very gentle motion in water
 breaks off a  great many of  their smaller branches.   They are
 solid, composed of lamina?, which  are easily separated from  each
 other, and are manifestly of a texture less and less firm as you ap
 proach the centre or axis, which consists of a white pappy mucus as
 thick as cream.  I observed one, about the size of a quill, which
 was tubular.  It seemed to consist of  a few lamellae only."
  In connexion with the plan of treatment already pointed out, it 13
 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 morbi! 
GE. Vn.—SP. VI.]    SANGUINEOUS FUNCTION.              239

action  excited in a remote organ, we have a strong invitation to
follow in a like path; and should  endeavour to obtain a like bene-
ficial result by the use of seatons or caustics.
                      SPECIES VII.

            EMPRESMA PNEUMONITIS.

                      Perfjmettmoug.

INFLAMMATION OF THE LUNGS;  OBTUSE PAIN IN THE CHEST;  CON-
   STANT DIFFICULTY OF RESPIRATION, ALLEVIATED BY  AN ERECT
   POSITION; TUMID,  PURPLE FACE OR LIPS J COUGH,  GENERALLY
   MOIST, OFTEN BLOODY; PULSE USUALLY  SOFT.

Inflammation of the lungs has been described under so many names
that it is scarcely worth while to give a list of them.   The most
common perhaps is peripneumonia, for  which pneumonitis, em-
ployed first, I believe, by Bourgard in his  Dissertation published in
1754, is here substituted merely on account of the regularity of its
termination.
   The disease as above characterized, is traced under the three
following varieties:—

«e  Vera.                    Fever a cauma;  pain severe,  little
   True Peripneumony.         expectoration in the beginning.
/5  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 side to the other; and, when the lower part of the 
240                     H/F.MATICA.           [CL. Ill—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 idiopatic  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 divison, and treated  of pneumonitis and  pleuritis as
distinct species, rather than varieties of one common species, which
is the view taken of  meningic and profound cephalitis.  In both
sets of disease, however, the membranous  is the more acute affec-
tion, evinces more violent and painful symptoms, and runs through
its course more rapidly.  And hence, in pneumonitis, as in meningic
phrensy, the pulse is  sometimes soft,t the fever small,! and the pro-
gress protracted occasionally to twenty days or more.§
  The causes of true peripneumony  are those of inflammation in
general;  particularly excessive  exertion  of the  lungs,  or  cold,
applied when the system is generally heated, to the skin, mouth, or,
stomach.  It attacks  the robust and plethoric more frequently than
the spare and delicate; and appears most frequently in cold weather,
or sudden  changes from  hot to  cold.  Repelled eruptions have
probably sometimes proved a cause;  and noxious exhalations cer-
tainly.   To the last we may refer  the frequency of this disease in
the outskirts of Mount Vesuvius, as remarked by Vivenzi ;|| and on
this account it is described by Baroniuslf and Bovillet,** as ende-
mic.
  The first symptoms  also are  those of inflammation in  general;
but there is usually more shivering, or cold fit, and the hot stage is
proportionally violent;  the head aches considerably, and the urine
is high-coloured. The pain in the chest is rarely felt in any oppres-
sive degree till these symptoms have continued for a day or two:
though sometimes it is coetaneous. The cough is short, peculiarly
distressing, and obstinate.  The pulse is variable,  in  some cases
hard and strong, in some soft or oppressed;  but with the advance
of the  disease, it becomes feeble, sometimes fluttering.  Delirium
* Morgagn. De Sed. et Caus. Morb. Ep. XXI. Art. 13,14, 37.
f De Cabalis, Phsenom. Med.
* Cleghorn. p. 262.
§ Stoll, Rat. Med. Part. II. p. 376. Act. Nat. Cur. vol. V. Obs. 124.
i Epist. ad Haller. iv.
1 Pleuropneumonia Ann. 1633. Flaminiam infestante.  Fidi. 1536.
•• Memoires sur les Pleuropneumonies epidemiques, p. 556. 
GE. VH.—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
rase 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 lake  place between the lungs and the pleura;
and sometimes  a collection  of water in different parts of the chest;
and not unfrequently a flow of blood,  apparently from the mouths
of the exhalants  without any rupture of vessels, giving  a bloody
tinge  to the sputum.   This  last has been  often regarded  as an
alarming  symptom, but the  alarm is altogether  unfounded, for it
generally affords considerable relief.   Indeed an  hemorrhage itself
from the lungs  has not always been attended with fatal consequen-
ces ; it has occasionally proved critical,  and carried off the disease
in a few days : though a hemorrhage from the nose, no unusual at-
tendant, is far preferable, as producing a like benefit with  less risk.
If the inflammation run into  suppuration, the change is generally
indicated  by  shiveringsy 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
and constitution of the patient, as also the situation in which he
resides; for if  he be in an open  and mountainous region, and ad-
dicted to the pursuits of a country life,  he will bear bleeding far
more  readily  and  freely than  if he  be the inhabitant of a crowded
city, or accustomed to a sedentary life.
  In this case the bleeding should  be prompt and copious, at least
to eighteen or  twenty ounces, and  repeated twelve hours after if
necessary ; and as the disease  occurs chiefly in robust constitutions,
it is rarely that venesection  can be  dispensed  with.  1 he chiet
evil is that the fever is apt,  at times, to run into a typhous form,
                     * Bat. Med. III. 53.
Vol. II.—H  h 
242
H^MATICA.
[CL. III.—OH. H.
and assume the  second of the varieties before us.   And hence,
where  there is any doubt upon the subject, local bleeding is to be
preferred, whether by leeches or cupping glasses, repeated accord-
ing as the evacuation appears to be demanded.   Laxatives and  re-
frigerants are next employed with the same general view of taking
off  the entony of the arterial system.   One of 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, I can recommend them when the disease has made a consider-
able advance:  but they must be used boldly, or so as to produce
full vomiting, and the action of vomiting must be maintained for an
hour, or even two :  and  in  this  way  they will often  produce a
transfer of action of as  beneficial a nature as the same process is
found  to do in purulent ophthalmy ; and will, at the same time,
peculiarly stimulate the exhalants of the lungs to  an  increased  se-
cretion of mucus.  Blisters, as is the common practice, ought to
form a concomitant in the general plan; and the  obstinacy of the
cough may be alleviated by demulcents, or inhaling  the steam of
warm  water.  Opiates have  been tried in every  form, but  have
never  been  found of decisive benefit: if opium be used at all it
should be in conjunction with gum ammoniac, or squills: but, upon
the whole, either of these expectorants seem to answer best with-
out opium.  Dr. Saunders recommended the extract of the white
poppy ; and that of the garden-lettuce has since  been tried  upon
the recommendation of Dr. Duncan; others may  have been more
fortunate than myself, but, in my hands,  both  have proved alto-
gether insignificant in their effects.
  If the disease proceed favourably the pulse becomes slower and
softer: the yellow tenacious, and perhaps bloody sputum, is mixed
with points of a whiter matter, which increases  with the amend-
ment of every other symptom; for the cough  is  less violent and
straining, the breathing freer, the skin moister,  and  the tongue
cleaner at the edges.   If  the progress be less favourable, the ex-
pectoration becomes darker and more viscid ; the pulse lower, in-
distinct, and often intermitting; a low, wandering delirium super-
 venes, with subsultus ; and the patient dies, apparently suffocated
 from the oppressed vessels no longer permitting an expansion of
 the lungs.
   When a salutary expectoration has commenced,  it sometimes
 ceases suddenly from some unknown cause, or some irregularity in
 the mode of  treatment.  This symptom  is alarming;  and every
 means should be instantly taken to bring the discharge back;  such,
 particularly, as increased  doses of the expectorants already noticed,
 to  which may be added the steam of vinegar, alone, or impregnat- 
GE. VII.—SP. VU.]   SANGUINEOUS FUNCTION.
243
  ed with the essential oil of aromatic plants, as rosemary.   And if a
  diarrhoea, which sometimes proves a very distressing concomitant,
  should supervene, it  will be  best  relieved by the pulvis cretae
  comp. cum opio.
    Inflammation of the lungs is, also, occasionally found as a symp-
  tom or sequel in rheumatism, lyssa, or canine madness, various ex-
  anthems, as small-pox, measles, miliaria, and commonly in phthisis;
  in which last  it has a very frequent tendency to suppuration, as we
  shall have to notice when treating of this distressing complaint.
    The malignant peripneumony, contrary to the true or common
  inflammatory  affection, is generally an epidemic, and may be easi-
  est explained  by  describing it as  an  epidemic synochus or typhus*
  occurring in such situations, at such seasons of the year, or in such
  a temperament of the atmosphere as has a tendency to  excite
  inflammation  of the lungs.  The debility is often so extreme from
  an  early  stage of the disease, that  the pulse ceases on the pres-
  sure  of  the finger;  and the vascular action  is too  weak  to ac-
  complish expectoration.   It is supposed by  many writers, and
  especially by Sarcone and Ludwig, to be a pulmonic erysipelas, by
  which they mean an erysipelatous erythema: and they are probably
  right in  their conjecture.  Whence Planchon regards erysipelas
  as its  proximate  cause.f   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 be pursued on the present occasion: for it
 will be in vain to attempt expectoration under circumstances in
 ■which  the system will probably sink  before the usual time arrives
 for. affecting it.  Camphor is  here a medicine of considerable ser-
 vice, and may  be used in conjunction with the aromatic confection,
 and  wine in large  quantities.  It should be taken freely in the form
 of pills, rather than in that of julep:  though both may be employ-
 ed conjointly.  Even the bark has  a powerful claim to be tried, and
 that too in as  large quantities  as in putrid fever; nor has it been
 found to produce difficulty of breathing.  It may be advantageously
 combined with the aromatic spirit of ammonia, which of itself often
 proves  a useful stimulus.   If evacuations be necessary they should
 be obtained by injections alone.   A light breathing perspiration, a
free expuition,  and a more animated appearance of the countenance,
are among the  most favourable diagnostics.

  • Pelargus, Medicinische Jalirgaoge I. i. p. 44. Tissot. sur 1'Epidemie en
Lausanne, &c.
  f Journ. de Med. Tom, XLVI. p.. 24. 
844
HJEMATICA.
[CL. HI.—OR. II
   The spurious or bastard peripneumony is usually allowed to of-
fer another variety of this disease; and is described under the name
of peripneumonia notha by Boerhaave, Coze, and Sydenham.   It is,
in many instances, little  more than a severe catarrhal  affection of
the lungs accompanied with great obstruction, occurring in habits
of a peculiar kind;  and is hence denominated  by many authors
catarrhus suffocativus.   It is characterized by great secretion and
expectoration, with a mild cauma; and is chiefly found in those of
advanced life, 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 hi6  description of the dis-
ease:—The  patient is hot and  cold alternately, feels  giddy, and
complains of an acute pain in the  head, especially when there is a
teazing cough.  He rejects all fluids, sometimes from paroxysms of
coughing, and sometimes without: the urine is turbid,  and of a
deep red; the blood appears as in pleurisy.  The patient breathes
quick and with difficulty: complains of a general pain  throughout
the entire breast, and  as he  coughs discovers  a wheezing to the
attendants.   The cheeks and eyes appear slightly inflamed;  the
pulse is small, often intermitting;  and lying low, or on  one side, is
peculiarly distressing.
  As the fever is here of no great moment, we may, with consider-
able advantage, carry our local  stimulants to a greater extent, and
thus excite the  lungs  more  actively to throw off the burden  of
mucus with which they are overpowered.   Squills, gum ammoniac,
balsam of Peru, and even some of the turpentines,  may be tried
and will mostly be found  serviceable.  The tetradynamia, as char-
lock, wild-rocket, and mustards of various  sorts;  and the alliaceous
plants will form useful auxiliaries in the plan of diet.  Blistering is
highly serviceable; after which, as soon as the chest is a  little un-
loaded, a regimen directly tonic should be commenced, by means
of bitters, chalybeate waters, a moderate  portion of wine, gentle
exercise, pure air, and  the irritation of an issue or seton; for a
common result of this disease is hydrothorax from atony of the ab-
sorbents of the chest.  And hence, perhaps, more frequently fall a
sacrifice to some sequel of the disease than to the disease itself. 
GE. VII.—SP. VIII.]  SANGUINEOUS FUNCTION.              245


                      SPECIES  VIII.


              EMPRESMA PLEURITIS.




ACUTE PAIN IN THE CHEST, INCREASED DURING INSPIRATION ; DIFFICUL-
  TY OF LYING ON ONE SIDE; PULSE HARD; SHORT, DRY, DISTRESS-
  ING COUGH.

As the proper seat of the preceding species is in the substance of
the lungs, or  the pleuritic membrane that  immediately  liies its
surface, or in  both, the proper seat of the present is in the sur-
rounding membranes of the pleura; and  as these differ, the differ-
ence has laid  some foundation for several varieties; of which the
three following may be noticed, as matter of curiosity, though the
subdivisions lead to nothing of practical  importance, as the causes
are nearly alike, and the same mode of  treatment is applicable to
the whole.
* Vera.                  Fever a cauma: pain felt chiefly on one
   True Pleurisy.           side: the inflammation commencing
                           in that part of the pleura which lines
                           the ribs.
/5 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.
 */ 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 diaphragm,

   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 mfle 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
HJEMAT1CA.
{CL. 1U.—OR. H.
 degree of pleurisy, so it is commonly affirmed that pleurisy rarely
 occurs without some degree of peripneumony ; in both which cases
 it has been called a pleuro-peripneumonia.   Like the latter we also
 find the former an occasional symptom or result of typhus, catarrh,
 rheumatism, and various exanthems.  The pleurisy, however, that
 is supposed to accompany rheumatism, is often an inflammatory af-
 fection of the intercostal or other thoracic muscles alone, since the
 pain is 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 is
 by no means uncommon ; in which case, if the abscess  do not point
 outwardly, an empyema will necessarily follow; and the formation
 of pus is indicated by a remission of the pain, one or more shiver-
 ing fits, and, in some instances, a sense of fluctuation.  This, how-
 ever, is a termination far more common to 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 less caution than in peripneumony.
  Perhaps there  is  no disease  in  which  profuse bleeding from a
large orifice may  be so fully depended upon, or has been so gene-
rally acceded to by practitioners of all ages and all  nations.   The
only question which has ever  arisen upon the subject being,  whe-
ther the blood should be taken from the side affected or from the op-
posite. The earlier Greeks recommended the former, the Galenists
and Arabians, the latter;  and  the dispute at one time rose so high
that the medical colleges themselves, not being able to determine
the point, the authority of the emperor Charles IX. was whimsical-
ly appealed to; who, with much confusion to the controversy, died
himself of a  pleurisy before he had delivered his judgment.   He
too had been bled, and his death was immediately ascribed to the
blood having been drawn from the wrong side.  At present from a
knowledge of the circulation of the blood, we can  smile at these
nugatory solemnities.   It is possible, however, that there are some
controversies of our own times, that have as little ground-work, and
;tt 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  dyspnoea, not at all relieved by  copious and re-
peated bleedings.  After death a slight effusion was discovered in
the pericardium : but the mediastinum was more inflamed than the
membrane of the heart.   The treatment of  this variety ought not
to differ from that  of the preceding.
   The cerebrum is, however, still more disposed to associate in the
morbid chain of action than in the heart.  And hence, when any of
the varieties of 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 para-
phrenias ; terms derived apparently from the peripatetic philosophy,
which supposed the seat of the Qpw, or soul,  to be  the praecordia ;
whence this region was denominated typim;  while, as Hippocrates
supposed its seat to be in the brain, phrenitis,  with a lamentable
confusion of terms, was,  as we have already remarked, applied  to
an inflammation of this last organ, and continues to be very gene-
rally  so applied in  the present day.
   It is in the last variety that the head is most commonly  affected J
probably  from the general sympathy which the 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 tightness 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
I1JEMAT1CA.
XL. 111.—OR. II
                       SPECIES IX.

                EMPRESMA CARDITIS.

                Kuflammatton of the ?l?eart.

 ;A1N IN THE REGION OF THE HEART, OFTEN PUNGENT ; ANXIETY} PAL-
                  PITATION ; IRREGULAR PULSE.

 The symptoms 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 than
 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 ihe 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 pass-
ing through vessels in a state of inflammatory action.  And it was
this discovery, and the hint thus founded upon  it, tuat gave rise to
the doctrine now so generally admitted, and apparently so well  sus- 
  £fc. VU.—SP. IX.]    SANGUINEOUS FUNCTION.              240

  tained, of a distinct secretion of pus, in many cases without ulcera-
  tion.
    The causes of carditis are often obscure : when we can trace therr,
  they are for  the most part those of pneumonitis; and the mode *f
  treatment needs not essentially vary.

                             11   i :

                         SPECIES X.

              EMPRESMA PERITONITIS.

              Kuflamraatton of the peritoneum.

9 PAIN AND  TENDERNESS OF THE ABDOMEN,  ESPECIALLY IN  AN EREC
    Pq^TURE; WITH  LITTLE AFFECTION OF THE  SUBJACENT VISCERA,
    OR ABDOMINAL 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 following
  varieties:—

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

    It is singular that Dr. Cullen, after distinctly characterizing 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 abdomjnal 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 mesen-
 tery.   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.—I i 
iS«0
H-flRMATICA.
[CL. III. —OR. H.
 ijcnown; 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
 ■have no specific symptoms by which they can be known, they have
 no more claim to be admitted into a system  of  symptomatic no-
 sology than into  a treatise of practice.  Dr. Cullen  is right in  as-
 signing them a place in the former; and  he is, therefore, necessarily
 wrong in banishing them from the latter; and the more 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 feritonitis occuio, as we haye already observed, as a
 symptom in puerperal fever; and as we have treated of it at some
 length under that disease, it is the less  necessary to  be minute in
 our account at present.  Puerperal fever, indeed, is sometimes,
 though not  quite correctly, made a variety of peritonitis : for it is
 a disease of a  peculiar  kind, produced  by peculiar causes, aqd is
 only  connected with peritonitis as the latter enters as a syrnptom
 into 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
 extraordinary 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
 effect it often happens that these are not at all influenced, and when-
 ever they are, it is only  secondarily.  " If the peritoneum,"  says
 Mr. Hunter," which lines the cavity of  the abdomen,  inflames, its
 inflammation does not affect the.parietes,.. oj Jtte^bdofaen; or if the
 pentonefim  covering any of tfie viscera is inflamed,\it does not affect
 .the viscera.   Th_us,.the jferitoneijm  shall  be universally  inflamed
 as#fn'*puerperal fever,  ye*t»tfie  parietes  of the abdomen, and the
 proper coats 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-
 pathize with the viscera which they cover.  The membranes  of
 the brain, as we  have already seen,  are so peculiarly disposed to
 partake of the inflammatory action of the parenabjma,  as' to raider
 solitary inflammation of  the one or the  other  a faj^ocqnrrence.
 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, p. 244. 
GE. VII.—SP. X.]    SANGUINEOUS FUNCTION.
251
 ter case, and, in many instances, not accompanied with sickness or
 any other disturbance of the alvine canal.
   The causes are those of inflammation in general, as cold,  exter-
 nal injuries,  and a morbid transfer of action;  and,  in a few cases,
 sympathy with the adjoining organs,  as in puerperal fever.
   The treatment is, in like manner, that of inflammation in general,'
 particularly that of e. enteritis, to which the reader's attention is
 especially directed.   Bleeding,  both general and  local, should be
 carried into effect copiously and with  all possible speed ; but purg-
 ing, though  at all times of service in inflammatory affections, is
 less imperiously demanded than in inflammation of the intestines.
 Warm stimulant fomentations may be advantageously applied to the
 abdomen, and blisters in succession :  but, after a very free use of
 leeches, I have found more benefit in applying a large folded flan-
 nel wrung out in simple hot water, or water impregnated with aro-
 matic herbs,  over" the Whole 6f the abdomen, and letting it remain
 there for many hours or till dry, wrapped over with a broad calico
 or flannel swathe that surrounds the entire body.   All we can pos-
 sibly aim at, in applications of this kind, is a continuation of moist
 warmth, as in a common poultice; and this is obtained more easily,
 and 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 in unison with ipecacuan or antimonials to de-
 termine to the surface.
  When the inflammation commences or is seated in the omentum
 or epiploon,  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 right 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 sanious secretion. Sauva-
 ges gives a striking example of this in a woman, who was at first at-
 tacked with an acute lancinating pain in the umbilical region; and
 had a tumour formed towards the right hypochondrium about the
 size of a man's fist, which by degrees 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, a trochar was introduced into both sides of
the abdomen, and a putrid ichorous fluid was discharged, which in-
duced the operator to enlarge  the opening; when sloughs of the
omentum  already separated came away with an intolerable stench,
and with about two pounds of what Sauvages calls ichorous water.
 But the  skill of the surgeon was overpowered by the disease, and
the patient fell a victim to it.*
  The mesentery has but a small degree of sensibility, and hence,
• Nosel. Med, Clws III, Ord. HI. XVI. 
*.<$.
HJEMATICA.
[CL. HI.—OU. 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 com-
monly  it is  catenated with  inflammation of the  spleen, liver, or
intestines.
  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 of  the Stomarh.

burning pain at the pit of the stomach, increased on swal-
  lowing ;  REJECTION of every thing;  hiccough; OPPRESSION
  AND DEJECTION OF MIND; 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,indeeds
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 terminating in  typhous  symptoms.  For this
kind of fever it is not difficult to account.  We have often had oc-
casion to state  that the stomach is the common centre of sympathy:,
it is also an organ of acute sensibility; and it is hence impossible
for it to suffer from inflammatory action without suffering severely.
and without extending its  affection  very widely.  The natural con-
sequence is, that there  must be great,  and general, and sudden
debility, and the fever, though commencing with excess of action,
may soon lead  to total atony,  and fatal consequences.

* Adhaesiva.                  The  pain  very acute; the fever
  Adhesive inflammation of the   violent.
    stomach.
/8 Erythematica.                With an  erythematous blush ex-
  Erythematic  inflammation  of   tending  to, and visible in  the
    the stomach.                fauces \ pain  more moderate;
                                fever less violent; pulse  low
                                and quick.

  Dr. Cullen seems lo  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. \n.—SP. XL]    SANGUINEOUS FUNCTION.              25S

justified the expediency of a  distinction.   This distinction, as al-
ready remarked, is produced by the nature of the  accompanying
fever ; 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 bpth varieties the causes are alike; as external or internal cold
suddenly applied in a heated state of the stomach, acrid substances,
or excess  in eating.  The acrid  substances  chiefly recorded are
jalap and other drastic purgatives taken  in excess; oil  of vitriol;
corrosive sublimate; and  very large doses of  nitre, or quantities
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
said 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
water 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. Cruickshank 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, " but she was dead before I 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, I found the contents of the
stomach in that cavity ; that they had produced peritoneal inflam-
mation, and killed. On examining the stomach, I 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
scrofulous  ulceration:  its edges had adhered  by inflammation to
  * Laflize, torn. LXXI.  Souville, torn.  LXXIII.
  | Kaltscbmied, Pr. de JEgro inflammatione ventriculidemortuocalculis, fcr.
Ten. 1757.
  i Pc la Fontaine, Chirurg. Med, 
tJ54
1IJ1MATICA.
[CL. HI.—OR. H
 the under surface of the 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."*
   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 repealed 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, after
 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, or 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 laxatives, 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 burst, a milk diet with the mildest food, and in small quan-
tities at a time, is the only plan to be 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 prae-
cordia, and languid or intermitting  pulse, which are its sure at-
tendants.
   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  suppu-
rative.  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 mosf
* Anatomy of the absorbent vessels, p. 122. 
JGE. VII.—SP. XL]    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,  tkc."*
   The erythematic inflammation of the stomach comes on more in-
 sidiously than the adhesive; and is best characterized 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 dis-
 turbance, for many days or even weeks.  De Haenf 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.
  1* On Blood, &c. p. 270.
  t Hat. Med. Part VI. IX. XIV. passim.
  j Beschreibung der Kennzeichen und Kunder Entz'undung des Magens und
der Gadarme, 
256
HJEMATICA.
[CL. HI.—OR. II
                       SPECIES XII.


              EMPRESMA ENTERITIS.

               Knflammatfon of the itotoels.

GRIPING PAIN IN THE BELLY ; TENDERNESS, AND VOMITING : FEVER A.
                           SYNOCHUS.


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
belong 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 Adhsesiva.            Very acute, fever violent; vomiting fre-
  Adhesive  inflammation   quent; and costiveness obstinate.
    of the blood.
/3 Erythematica.          Pain more moderate ; fever less violent;
  Erythematic inflamma-    little vomiting,  and diarrhoea instead
    tion of the bowels.      of 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 undergastritis 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 FUNCTOIN.
257
discharged with difficulty; the breathing is laborious; and from the
contraction of the abdominal muscies 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  stomach.  At length
'he torture suddenly diminishes; and the  patient appears to  have
'.btained relief: but his pulse intermits, his face grows pale, his ex-
<. entities cold, convulsions succeed, and he sinks in death.
   The general termination, therefore, when unfortunate,  is that of
p,:.: grene ; for it js 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
j eat,  and increased  from the tendency of the stomach  to reject
■whatever medicines are introduced into it.  Most practitioners com-
i ience 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
lancet 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 bene-
fit by it than in peritonitis.
   From 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 this is rarely the case: 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 ihem.
  It does not necessarily follow that the  irritation of these more
acrid purgatives will add to the inflammatory irritation; nor do we

                     * IlM/Novyav, 1H. p. 491.
  Vol. II.—K k 
558
HJEMATICA.
ICL. IU.—OR. II.
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 from
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 is
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 costive-
ness if given alone, and retard the effect of purgatives if given in
conjunction with them. Nevertheless, if, after copious bleeding, the
costiveness 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 ca-
thartic will answer readily, and sometimes  the bowels have been
moved 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 advisable,
I prefer the epithem of a folded flannel wrung out in hot water, and
confined with a swathe, as already recommended in peritoneal in-
flammation, 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 revolutioiv
takes place,  and stools are evacuated;  and this, too, after the  ex-
tremities  have begun to grow cold,  and  an apparently deadly lan-
guor 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. 
 GE. VU.—SP. XH.]  SANGUINEOUS FUNCTION.               259

 charge from the bowels, of which, with the liberal plan now recom-
 mended, we need net 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 ihe 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 buffy coating; the sickness incessant, with deep anxiety
 and oppression. 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 that it had
-extended up the whole of the oesophagus.   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 in-
 fusion of roses, cascarilla bark, and cinchona, supply its place.
   I 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 communicat-
 ed by  Dr. Latham :i  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 rjbrtion 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

  * Disser. sistens Observations circa fallaciam signorum in inflammationibus
 \bdominalibus. Haffn. 1776.
  f Plocquet, Initia. Vol. V. 108.
  t Vol. IV. Art. XXIV. 
260
HJEMATICA.
[(I. III.—OR. •
the line of gangrene; the latter to a length of not less than fifty
seven inches, measured 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 power, however, of restraining his motions, so as to postpone thr
evacuation.



                      SPECIES  XIII.

              EMPRESMA HEPATITIS.

                Xnflammattoii of the  2tibei\

TENSION,  SORENESS, AND PAIN  IN THE REGION OF THE LIVER; PAIN
   ABOUT THE RIGHT SHOULDER; DIFFICULTY OF LYING ON THE LEFT
   SIDE ; 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.

« Acuta.                    In which  the above symptoms are
   Acute inflammation of the     clearly  marked, and the charac-
     liver.                      ter of the disease is decisive.
 £ Chronica.                  In which the  specific character is
   Chronic inflammation of the   obscure; and the  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; chillness, 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. VII.—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
diaphragm to the seat of disease, and its sympathy  with the liver.
The sickness of the stomach  is from the same cause.
   The disease is  sometimes accompanied with a jaundiced colour of
the skin : and Sauvages and Sagar 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 tp 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 portae.  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-
 vtfable,  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  inmost 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  of breathing.  If adhesions 
262
1KL.MATICA.
[CL. 111.—OR. II.
 have preceded the suppuration, the pus points to the skin, and the
 abscess opens on the surface; but if it break internally it generally
 proves fatal by inducing a hectic, though sometimes in consequence
 of fortunate adhesions, the abscess discharges itself into the hepatic
 duct, and the pus is carried off by this channel.  It has, occasionally,
 by the same means, made its way into the stomach and intestines,
 where the abscess has been very large.  In which case, however,
 immediately upon the bursting of the vomica, the patient throws oft',
 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 atTrincomale, 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 conr^j^i.iK"'
 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 te be prescribed as speedily

  • Letter to the Editor of the Medical and Physical Journal, May 1798. 
GE. VII.-9P. Xni.]   SANGUINEOUS FUNCTION.               263

as possible; certainly before the fifth day; and be repeated generally
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 im-
prove under it; the soreness and tension subsiding,  the cough di-
 minishing, 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 mofe 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; parties
 larly the  antimonial preparations.  Cooling, diluent, and even aci-
 dulated drinks should be taken  copiously ; the diet consist chiefly
 of light farinacious 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 maturing
 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 sub-
 sequent tumours ensue, and subsequent openings are necessary.!
   It is not always, however, even after suppuration has taken place,
 that the  abscess must necessarily  open in any direction; for the
 following case will show that when we have full reason to believe
  * Medical Sketches, passim.
  f Recueil d'Observations de Medicine des Hdpitaux Militairqs. &c. Art. pn '
M. Boucher, torn. II. 4to. Paris. 
 264                     HJEMATICA,            [CL. HI.—OK. H.

 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 of high
 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 mixture
 of symptoms that gave no small degree of obscurity  to the real
 nature of the complaint.   The bowels were at this time obstinately
 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 considerable de-
 gree of tension and tenderness in the hypogastrium, rather verging
 towards the right, and connecting these signs with the preceding,!
 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.
 This 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
 hundred 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
 troublesome; 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 elaierium, generally increased to ihree grains at a dose,
in conjunction with the same quantity of extract of jalap, was given
asapuige.   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 fit e doses together with the  calomel.
  At this lime a violent  shivering-fit took place,  which made the
teeth chatter; thi- 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 was now  affected.  The former treat-
ment was  resumed ;  leeches, succeeded by an ammoniac-mercurial
plaster,  were applied 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,
thai the first and last inflammations were  carried off by  resolution;
and the second by suppuration, the pus being absorbed and the ca-
vity healing without exposure.
  In chronic hepatitis all the specific symptoms, as already observ-
ed, show themselves obscurely.  The 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
  Vol. II.—LI 
266
HJEMAT1CA
MJL.IU.—Olt.ll.
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, fullness in
the right hypochondrium, white stools, yellow complexions, 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  secernents 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 recomended 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 advisable to  employ the decoction.
   In slighter cases,  which have nevertheless  compelled a return
from India after a residence of eight or nine years, I  have found  all
the symptoms vanish before a steady use of Plummer's or the blue-
pill, taken every night for a month ; and the  Cheltenham air and
waters, for the same period  of time, afterwards.
   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.  These  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. § 928—4. Hippocr. in prognostic, torn. VUI, p.
613.  Galen He Crisibus.  lib. III. «ap. IV. 
GE. VII.  SP. XHL] 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 kxt ebivaiptx*, 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.

                Knaammatton of the Spleen.

 HEAT, FULNESS, AND  TENDERNESS  IN THE SPLENIC  REGION J  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  conjestive and
 scirrhous.
  Inflammation of the spleen, together with the symptoms given in
 the  definition, is accompanied with the usual pyretic 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 constriction 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.*

  • Eph. Nat. Cur. Dec. I, Ann. IV. V. Obs, 164. Ann. VII. Obs. 150. Vallis-
neri, opp. HI. p, 128. 
2M-;                      HJEMATICA.           [CL. HI—OK. II.


                       SPECIES  XV.

               EMPRESMA NEPHRITIS.

              inflammation of tfie  Bfimcss.

TAIN IN Till;  RENAL REGION J FREQUENT MICTURITION; VOMITING J
  NUMBNESS OF THE THIGH ON THE AFFECTED SIDE J RETRACTION OK
  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 costive, and  motion, and even an erect  position, is accompa-
nied with considerable uneasiness.  By the last sign we may distin-
guish the disease  from an inflammation of the psoas, or almost any
other adjacent muscle : while 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 the 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 lhat an abscess
will  ensue: in  which  event  the  pus  maybe 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 remis-
sion 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 kidneys.   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.

              Xnflammatfon of the BlaoUet*.

PAIN AND SWELLING IN THE HYPOGASTRIC REGION; PAINFUL OR OB-
           STRUCTED DISCHARGE OF URINE J TENESMUS.

The bladder isoften 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
HA1MATICA.
[CL. III.—OK. II.
usually great restlessness and anxiety, with cold extremeties, vomit-
ing, delirium, and other marks of great general irritation :  the dis-
ease runs its course with rapidity,  and subsides, or destroys  the
patient, 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 ihe 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.

               Knflammatfon of the Womb.

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

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

« Simplex.                  The  organ   unimpregnated.  Pain
  Simple Inflammation of the    permanent, circumscribed, throb-
   Womb,                    bing : fever a cauma.
C 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- 
GE. 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 Maternity, 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 he,
•' en a ete souvent frappee, mais  une fois entr' autres elle ete entiere-
ment detruit entierement fondue: il n'en restoit aucune trace, si non
un foyer defluide  sanieux, dans la region, et en place decetorgane."
   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, 
972
HAEMATIC A.
|CL. III.—OK. 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.

              Knflammatton of the Eesticles.

?AIN AND SWELLING OF THE TESTICLES;  NAUSEA OR VOMITING;  DE-
      PRESSION 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. VII.—SP. XVIH.]  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,f and  is a  common mode of
treatment on the continent, particularly in  Germany :t  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.

        ©imthalmg.   Knflammatton of the 2£se.

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

Ophthalmia, from the Greek term o$«x\(m<„ 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.
f Continent Lib. XI.
\ Althof, Practische Bemerkungen, &c.
  Girtanner, Venerische Krankheiten, &c.
Vol. II.—M m 
274
IIJEMATICA.
[CL. III.—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, and 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 ophthalmy.  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 sin-
 gle organ. 
GE. vm.]
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.            LACHRYMOSE OPHTHALMY.
2.____________IRIDIS.              INFLAMMATION OF THE IRIS.
3;------------PURULENTA.         PURULENT OPHTHALMY.

4.------------GLUTINOSA.          GLUTINOUS OPHTHALMY.

5,------------CHRONICA.           LIPPITUDE BLEAR-EYE.
                       SPECIES I.

             OPHTHALMIA TARAXIS.

                Saehrgmoae ©jmthalms.

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 olher 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 rxpxo-o-u, " 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.                   The inflammation limited to the sur-
   Mild Lachrymose          face: the pain passable: the head
    Ophthalmy.             not affected.
0  Acuta.                   The  inflammation extending  to the
   Acute Lachrymose         lpwer  part of the  eye-ball:  and
    Ophthalmy.              sometimes commencing there: the
                             pain burning: the tears perpetual
                             and acrid: with intolerable head-
                             ache. 
276
ILEMAT1CA.
[CL. HI.—OR. 11.
  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 seasons, are ano-
ther common cause; as is also an exposure to smoke, or other acrid
fumes or exhalations.  A strong incessant glare of light, or of vivid
colours, has also not unfrequently proved a source of affection; but
perhaps less frequently so than an  undue use of wine  and ardent
spirits.
  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 fine
membrane that lines their interior is turgid with blood, and there
is arfeeling 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 easily
removed by local applications,  and particularly astringent lotions,
as cold water, or solutions of alum, zinc, or lead j*  though in irri-
table  habits of a particular kind, relaxants and anodyne  fomenta-
tions prove most successful. And even when the first are em-
ployed, 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-glass-
es, 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 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.

         * Janui, Beobachtungen iiber das auge, &c. Berl. 1776. 
GE. V11L—SP. 1.]    SANGUINEOUS FUNCTION.                277

  I have known, however, 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 suc-
cess in a very strongly marked case, published by  Dr. Robert
Dobsonof Kirkham; who tells us that  at that  time, 1773, there
was a rumour of  the utility of emetics in some  inveterate cases ot
this kind, notwithstanding the general prejudice  against  them, trom
their being supposed to add to the congestion of the head.   1 he
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 ot
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,
 and 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 becr-
 tim'e, she  took a grain and a half of Thebaic extract with tvyo grains
 of iDecacuan.  She passed a quiet  and composed night, and enjoyed
 mofe 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 ihe inflammation is a mere symptom or concomitant o
  some other disease, it can only be  removed by a cure  of the original
  malady.  And this is not unfrequently  the case; for it is often de,
  nended on a  strumous, or syphilitic habit, or a suppressed blenor-
  rhcoa: on a disordered state of the stomach, liver or  some other di-
  gestive organ, and especially in hard drinkers; on an abuse of mer-
  cury  as a medicine; and on various affections of the teeth.
    If  the  inflammation be produced by an influx of sand or gravel,
  or sniculx of flint or iron driven into ihe external tunic, every such
  foreien substance must  be carefully removed  with as much  speed
  as possible:  but it will  be  generally found that  the  pointedjind

                     • Edin,. Med. Com. HI. p, 411 
278
HJEMATICA.
[CL. III.—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 fixed in the membrane.  We have various
examples of an extraction of spiculae of iron forcibly  driven  into
the eye, by the application of a magnet.*



                       SPECIES II.


                OPHTHALMIA IRIDIS.

                Xnflammatton of the Krts.

INFLAMMATION COMMENCING IN THE IRIS ; COLOUR CHANGED TO GREETv
  OR REDDISH; FIBRES LESS MOVEABLE;  AND SHOOTING DENTIFORM
  PROCESSES  INTO THE PUPIL ;  PUPIL IRREGULARLY  CONTRACTED
  AND GRAYISH.

  Dr. Schmidt of Vienna, to whom we are chiefly indebted for an ac-
curate description of this species, has denominated it Iritis ;\  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 irif/itis instead of iritis; but ophthalmia irides is belter, 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  grayish or blue,
the morbid hue will be green: if brown or black, it will be reddish.
The grayish 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. XIII. 22.
  "Weber, Wiirkung des kunstlichen Magnets in einem Augenfeler, p. IB
Hanov. 1767, 8vo. Phil. Trans, p. 164.
  t Ueber Nachstaar, und Iritis Nachstaar operationem. Wien. 1801, 
GE. V11I.—SP. II.]   SANGUINEOUS FUNCTION.              279

pupil is closed or rather filled up  by  the  grayish 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
internal 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 as adhesive alone.  And he tells us
  that inflammation of the cornea so strictly maintains this character,
  that if it spreads to the iris, and in this case become merely secon-
  dary, 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
1ULMAT1CA.
[GL.IH.—OR. II
                      SPECIES III.

            OPHTHALMIA PURULENTA.

                  purulent #jmthalm£>.

THE INTERNAL  SURFACE OF THE PALPEBRJE ASSOCIATING IN THE IN-
  FLAMMATION 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:

« Epidemica.               The disease epidemic;  inflammation
  Egyptian ophthalmy.        rapid and destructive, producing
                             irritating granulations on the inner
                             surface  of the palpebrae:  head-
                             ache intolerable; often succeeded
                             by delirium: at times remittent.
/3 Metastatica.              Apparently  produced by a sudden
  Metastatic ophthalmy.       suppression  of catarrhal, blenor-
                             rhoic, 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.
f 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. V1H.—SP. m.]   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 symptoms 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 irritalion is hereby still kept up, which becomes a
secondary source of blindness.
  The earliest mode of  treatment pursued  by the  French, as we
  Vol. 1I.—N n 
282
Il-EMATICA.
[CL. III.—OU. II.
 learn from the  account of Dr. Antonio Savaresi, consisted in little
 more than the general treatment of the common acute ophthalmy;
 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 of treatment
 thus limited, completely failed of success: 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-
 pebrae, 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  ihe
 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 re?
turn of the British army;  By J. Veitch, M. D. 
<^E VIII.—SP.IH.]    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 ophlhalmies of
  a like chronic kind, accompanied with nervous  debility ;  the bark
 being interposed between their repetition.f  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 urethra from venereal in-
 fection.
   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 ihe 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.   I 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. II. p. 102.
fMed. Comm. Edinb. Vol. III. p. 444. 
:84
HjEMATICA,
[CL. III.—OR. II.
mia catarrhalis and o. gonorrhoica.  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 eyej
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 former ;
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   ihe 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 mucus 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 I 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 i 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.  Itistheophthalmia/zeriod/caofPlenck.  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 bette:*
 chance of success.
   The fourth variety is called by Mr. Ware  the purulent  opu 
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 fs 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 accom-
panied with eruptions on the head and other parts of the body; and
sometimes with signs of a scrofulous 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
afford, 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.   I
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-
mation was less violent than in 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, Florophthalmy, and purulent Eyes of new-
orn Infants. Edit. Tec, 1814.' 
2£b
HEMATIC A
[OL. HI — OR. IT.
   The plan that has proved most effectual, in my own course of
 observation 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 lo 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
 spatula, or some other blunt instrument, and the point of the syringe
 loaded with the astringent lotions should then be introduced between
 them, and convey its contents all around; the syringing being re-
 peated 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 kepi 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 in
the form of an ointment, by means of the unguentum cetacei. By a
careful perseverance in this process I  have  not only seen ulcera-
 tions on the cornea heal speedily, but in one or two instances, with-
out leaving any cicatrix to impede the vision, even where the ulce-
ration has been seated over the pupil. 
 OE. VIII.—SP. IV.]   SANGUINEOUS FUNCTION.             287


                        SPECIES IV.

             OPHTHALMIA  GLUTINOSA.

                   Gflutinous ©phthalmg.

 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 ULCERATE.S THE EDGES, AND IRRI-
   TATES THE EYE.

 This 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 unfrequently  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 of a
 scrofulous 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 Mr. 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 nitrati, 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
 Mined 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-
 dle.  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 repeated
daily. 
^88                    HA.MATICA.            [CL.H1.—0R.I1,


                       SPECIES V.

             OPHTHALMIA  LIPPITUDO,

                        HtjiIHtutre,

EYE WEAK AND WEEPING, WITH SLIGHT BUT CHRONIC INFLAMMATION ,
  TARSUS THICKENED, SOMETIMES EVERTED, WITH A PERMANENT RED-
  NESS 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 maybe
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 
I..E. V11I.—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 thymalsea 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  progress,  of extirpating the whole
fungus close  to the external muscular substance ot 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  much, 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 eyelid, 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.^   The hairs of the eye-lashes prove
a great source of irritation: but the disease  maybe  removed by
some of the  means just  described.
• Remarks on the Ophthalmy, p. 40.
f Practical Observations on Ectropium, &c. Chap. I.
* Planner, De Vulneribus superciliis illatis. Opusc. torn. H.
Vol. II.—O o 
290                      H/EMAT1CA.           [CL. III.—OR. 11.



                       GENUS  IX.

                    CATARRHUS.

                          <£atarrh.

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

Catarrh is a Greek compound,and imports " defluxion," from %xrx,
denoting, as  stated ia ihe table of significations to the affixes and
suffixes of medical terms in the Nosology, " augmented action," and
pea>,  " 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,
had  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, cystirrhcea, leucorrheca,
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, dicatur rheuma Catarrhus;
           Ad fauces, Bronchus; ad nares, esto Coriza.

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;  antiad.e,  when  the  tonsils;
and paristhmia, when the attack was common to the fauces.   For all
these Celsus employs the Latin term ghavedo,between which, how-
ever, and coryza, he observes that there is a manifest  difference.
It is 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 Ihe vocal avenues, is made to import 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-
 i agmus.
   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, anywhere 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. El'lDEMICUS.          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

               <Eol& in the f^eati or ehest.

       fever slight;  mucous discharge considerable.

This isthe/ioae of old English writers, aterm precisely synonymous
wimLgrivedo of CelsSs, which is also employed  in the earlier
radical works of our own country. To pose is sti  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 Sfi head, and of weight over the  eyes, which are  inflamed  and
 achrvmose   The  nostrils are obstructed, and pour  forth a thick
acr momous icn0r,  which excoriates the skin  as it descends, accom- 
292
HEMATIC A.
LCL. 111.—OR. II
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 se-
cretion is obstructed in its flow, it is  transferred to, and passes off
with the  latter;  the cough being produced by the  stimulus of the
increased action, and exhalation.
  There seems, however, to be, in many cases at least,  something
more  than this ; for neither cold nor  suppressed  perspiration will
account  for every instance  of common catarrh.  There are few
practitioners,  perhaps, but  have sometimes  known persons thus
affected 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
constitution at the moment;  and  something upon the variable qua-
lity 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. 
tiE. IX — SP. II.]     SANGUINEOUS FUNCTION.               293


                       SPECIES II.


            CATARRHUS  EPIDEMICUS.

                         Knflucma.

the attack sudden ; great heaviness over the eyes ;  FEVEK
              STRIKINGLY  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 lo its diagnostic character.
   It commences, according to Dr. J. C. Smith, who has accurately
given us its progress 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;  ihe 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
HA.MATICA.          [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 se-
cond 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 for
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 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 conti-
nued to the end  of November, after  which  they abated, but the
fever still remained the same  as it  was before  the catarrhs appear-
ed;" meaning that it  then returned  to  its essential character:
"although," he continues,  " it was neither quite so  epidemic, nor
accompanied with quite the same symptoms;  since  these inciden-
tally depended upon the catarrhs."
   Influenza, however, as we shall have occasion to show.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 meteorogical phaenomena that
vie 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 indefatigible 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 ©EION,* and not some unknown
and latent physical principle of the atmosphere, as various exposi-
tors  have conceived : " non enim quaecunque causas habent incog-
nitas 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 intemperamtnt, 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 atmo-
sphere'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.t  Others, without undertaking to determine in what  the atmo-
spheric 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 at-
mosphere, 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 ma-
nifestly trace such an origin ;  and, as we have  already shown that
  • De Prognost. Lib. I.
  ■f- Comment, in Progn. Hipp.
  $ Rahn. liriefwachsel, mit seinen chemaligen, Schiilern. Band. n. Zurich,
Svo. 1787.
  § See especially De Mertens Obscrv. Med. torn. II. 4. and Simmons, Lond.
Med. Jonrn. 1788. P. IV. 
296
HJKMAT1UA
[CL. Ill—OR. 11.
 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 afterwards, " during
 the action of the fever thus produced, the effluvium from the living
 body 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 formation; under which form it is commonly
 known by the name of contagion."
   I may now add that as primary febrile miasm is not ihe 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 ophthalmy, or from the urethra in ble-
 norrhcea, 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  accompa-
 nied with so violent a degree of fever as to be peculiarly dangerous,
 especially  to the young of these kinds. In South America, in par-
 ticular, this affection is so violent that half the dogs pupped there
 are supposed to die of it while sucklings.  Whence in common
 language it is called emphatically the distemper, though vulgarly
 the snaffles, or rather snuffles, from  the state of the nostrils.  In
 nosology it is commonly called catarrhus caninus.
  Generally speaking, specific miasms and contagions capable 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 not 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, are
* Class II. 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  conseqaence of being
crowded in a ship, they all died of a febrile disorder."—" In the ex-
pedition to Quibcron 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 by
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 re-
mainder 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 soldier*
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. Chirurg. Trans.  IV  89. 475.
f Med. Trans.  Vol. III. p. 59.
* Dr. Hamilton, Mem. Med. Soc of Load* 1782.
Vol. II.—P P 
£98
HJEMATICA.
[CL. HI.—OR. U.
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,  were  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."t
   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 phaenomena have been much
the same;  and the disease has always been particularly  remarkable
in this, that it has  been  the most  widely and generally spreading
epidemic known.   It  has seldom appeared  in  any one country of
Europe, without appearing successively in every other part of  it."
And, in some instances, the infection  has passed the Atlantic with
little or no remission of its severity, and attacked  Americans, who
had not had the  slightest intercourse with Europeans.
   And hence we are capable of tracing it at  sea as well as on land.
In the epidemy of  1782, Lord Anson  sailed  in the month of May,
with a fleet for the Dutch coast; and Admiral Kcmpenfelt 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.f
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. Ill p. 56
f Mem. Med. Soc. of Lond. ut supra.
* Dr. Heberden, Med. Transact. I. Art. XVIU. 
GE. IX.—SP. H]    SANGUINEOUS FUNCTION.
299
the Atlantic, and  arrived the ensuing year in America.   But this
assertion wants confirmation.  If we allow its materies to depend
upon  specific  miasm floating in the atmosphere, we can only ac-
count for its preserving its  agency so long, and operating in such
distant theatres, by supposing that its particles are with great diffi-
culty dissolved or decomposed in the air, even when in its purest state
or highest degree of agitation by tempests.   Of the specific miasn.s
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 confined peripheries;  while others are  only
dissoluble in a pure atmosphere, and consequently retain all their
virulence in an air already saturated with  other foreign  elements:
properties which  the author has already endeavoured to  exemplify
and illustrate in the inquiry into the Remote Cause of Fever.*
  The chief influenzas that  have visited  Europe  within the last
three centuries, occurred in the following order of time: 1510;
1557;  1580;  1587;  1591;  1675;  1709; 1732-3;  1743; 1762;
1767; 1775; 1781 and 1782: since which  period 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
of dipnoe, will usually be found sufficient, if the bowels be kept free
from  confinement.  If  the chest  be much loaded, an emetic will af-
ford the best  relief.   And if the cough be  troublesome,  and the
breathing laborious, both 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.f   But it generally agrees better in common ca-
tarrhs than in influenza.  The subsequent  debility may be removed
by a free use of the bark, gentle exercise, pure air, cold bathing,
and a liberal regimen: which  last, indeed, should be  continued
through the disease itself.  The cough  occasionally produced, re-
mains sometimes as a sequel long after the  other symptoms  have
disappeared:  and, in this case, opium with  camphor, or the  resi-
nous  balsams, often affords essential relief, and especially at night;
yet it has not been found that even the symptom of a cough has
proved  any  impediment to the  use of the bark, or even to that of
• Vol II. p. 53.
f Mat. Med. Part H. Ch. VI. 
soo
IUEMATICA.
[CL. in.—OX. U.
cold bathing, or been augmented by the practice, as influenza has
rarely terminated in  phthisis : and according to Dr. Carmichael
Smith, is less disposed to produce this complaint than a common
catarrh.
                       GENUS X.

                    DYSENTERIA.



inflammation of the mucous membrane of the largeii intes-
  tines; griping and tenesmus; frequent and often bloody de-
  jections ; THE feces seldom discharged, and in small quanti-
  ties.

From the mixed character of this malady there is some difficulty in
fixing its exact place in a nosological classification.   The severe
local symptoms give it a  close affinity to the enteric diseases; while
the fever that is so general, though not a constant concomitant, of-
ten most alarming from its  violence and malignity, and frequently
assuming a remittent character, seems to mark it for some order in
the pyrectic class.
  There is also another discussion to which dysentery has given
rise, and which has sometimes been conducted with  considerable
warmth.  When it is accompanied with a high degree of fever, and
a copious discharge of mucous, bloody, membranous, or filmy mat-
ter, it is admitted on all hands to be contagious, though it has been
debated whether the matter of  contagion is thrown forth from the
body of the sick, or from the putrescent recrements. But the grand
question that has been  agitated is, whether dysentery ever exists
without contagion ?  or, in other words, whether, when the disease
exists without those virulent symptoms which are clearly indicative
of contagion, it is entitled to the  name of dysentery ?
  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 pyrexia,
but generically distinguished it by the character of pyrexia contagio-
sa :  asserting in his Synopsis,  that he  has never  met  with more
than one species; and still more  distinctly in his First Lines, that
" the disease is always contagious," and that the contagion is proba-
bly at all times specific*
   Dr Parr and Dr. Young  make a nearer approach to the general
«————^—                           —          . i    i ——
              • Part. I. Book V.  Chap. II. Sect. MLXXV. 
GE. X.J
SANGUINEOUS FUNCTION.
SOI
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 lo 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 acute 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, 1 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 accessit  nunc aberat.  " At times," says he," the dysentery
 commences with rigor and shivering,  succeeded  by a heat of the
 whole body, as is the case in fevers—but frequently there is no ap- 
302
HJEMATICA.
[CL. 1U.—Oil. II.
pearance of fever, for the host of gripings take the lead, and the de-
jections follow."   He pursues his description of  the simple dysen-
tery, or that without fever, observing that in this species an excre-
mentitious stool is sometimes interposed without considerable pain;
and then enters upon the species accompanied with fever.  uIn 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  purse his description of this second species
further.  It must be  obvious to every one, that, in the opinion of
Sydenham, dysentery,  as  a genus, embraces at least  two distinct
species, both of which, at the period of his writing, were epidemic ;
the one of  a milder nature without fever, the other of a malignant
nature with it.
  The former of these is often met with in private practice, of spo-
radic origin, and without evincing any contagious character.   The
latter is, perhaps, as Dr.  Cullen  asserts, at all  times contagious.
Since writing the above, the author has met with Dr. Harty's " Ob-
servations  on the Simple Dysentery and  its  Combinations,  con-
taining a review of themost 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 be
at times, no contagion, and little or no fever, there seems to be al-
ways some degree of inflammation  in the colon or rectum, occasion-
ally perhaps extending  higher; an inflammation of a peculiar kind,
with a strong  tendency, when violent, to run  rapidly into a state of
gangrene;  but, when milder, exciting that increased flow of mucus,
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 dis-
eases ; though,from too close an adherence to the concurrent arrange-
ment of the earlier nosologists, it will be found placed, in the phy-
siological synopsis, under the order enterica  of the class Cceliaca,
a position which I now beg the reader to correct.
  The febris  nova or dysenterica of Sydenham seems hardly enti-
tled to consideration  as a distinct species.  It was the common epi-
demy of the season, accompanied with or succeeded by a few of the
slightest symptoms of dysentery, without the  pathognomic evacua-
tions.   Putting this, therefore, out of the question, dysenteria, as
contemplated  by this great writer, and as confirmed by ihe general
experience of the present  day, seems to include  the two following
secies:

1. DYSENTERIA SIMPLEX.               SIMPLE DYSENTERY.
2, ---    ., , ., pyrectIOA.              DYSENTERIC FEVER. 
GE. X.—SP. IM      SANGUINEOUS FUNCTION.               303


                        SPECIES  I.

               DYSENTERIA SIMPLEX.

                     Simple Sfismtcrg.

 FEVER SLIGHT OR UNPERCEIVliD ; THE FECES, WHEN  DISCHARGED)
   EVACUATED WITHOUT CONSIDERABLE PAIN, OF A NATURAL QUALITY
   AND AFFORDING EASE.

 The atmospheric temperaments chiefly calculated to produce severe
 bowel complaints are those of summer and autumn ; when the liver
 is excited to a larger secretion of perhaps more pungent bile, from
 the greater heat of the weather ;  the skin is exposed lo 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
 to be combined with fevers of various kinds and various degrees,
 so as to render the complaint  peculiarly complicated and danger-
 ous ; though we have not yet been able to find  out what are the
 precise causes  that, operating  locally, produce the distinctive
 symptoms of dysentery rather than those of diarrhoea,  cholera,  or
 any other irritation or  spasmodic  action of  the  intestinal  canal.
 This may, perhaps,  sometimes depend  upon idiosyncrasy, some-
 times upon accident, and, in the severer cases, upon contagion or a
 specific miasm.
   The symptoms, 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 are 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 ;f while  Piso contends
• Nat. Med 1'art. III. p. 294—826.
t Cawley, JLond. Med, Journ. 1786. 
 301                      H-EMATICA.          [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 loosenesa
 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 dysenery, 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 disenterie : and which  Rolander, who laboured un-
 der repeated attacks of this affection while  residing with Linneus,
 pretended to trace from water deposited in a cistern of juniper-
 wood, f
  The ordinary exciting cause of simple dysentery,  there can be
 little  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 aestival and autumnal months; and
 occasionally as an epidemic of the season.   But by what means this
 exciting cause operates  upon the larger intestines rather than upon
 any other cavity, or  produces the symptoms of dysentery rather
 than those of diarrhoea, cholera, or colic, we seem to be incapable
 of determining.  We perceive, however, in the events of every
 day, that sudden chills on the surface are  possessed  of a revellent
 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
• Discours sur la Nature, &c. des Maladies accompagnces de Dysenteric
t Amoen. Acad. V. 82 et alibi. 
GE. X.—SP. I.]      SANGUINEOUS FUNCTION.
305
character the three diseases have by some pathologists been con-
ceived to be so much alike, that dysentery has been regarded as an
intestinal rheumatism by Coelius Aurelianus, Akenside,  Stoll, and
Richier: 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 l<»ad  and the
dejections  follow.  The gripings are  always severe, and a sort of
painful descent of the bowels accompanies every evacuation.   The
discharges  are chiefly mucus, but  an  excrementitious stool some-
times  intervenes without considerable pain.  The  mucous stools
are generally  streaked with blood ; but in  some cases there is no
such appearance through the whole course of the disease.  Never-
theless, if  the stools be frequent, 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 ihe proportion  of half an
ounce of the first, two drachms of the  second, and a drachm  and a
half of the  third. " I prefer," says he, " the use  of rhubarb in this
form to giving it alone or in a smaller quantity, because unless  it
acts thoroughly  it does not much conduce to a cure ; and because,
also, though  more  powerful cathartics might be employed, they
would but aggravate the gripings and increase the general disorder,
and especially the depression of spirits. And hence even after the
rhubarb purge, I commonly  give the anodyne at an earlier  hour
than usual; indeed at any time in the afternoon, as soon as the
laxative has ceased  to operate, and thus get rid of the excitement
it has occasioned.  This purgative I repeat twice every other day,
always following up the dose with an anodyne as above; and I re-
sort to the anodyne every  morning and evening,  even when no
aperient is given, that I may  repress the violence of the symptoms,
and gain a truce while I  am evacuating the peccant  humour.   The
anodyne I  make use of is sixteen or eighteen drops of laudanum in
a dose of cordial-water of any kind : and after the first bleeding and
purging, I  allow any temperate cardiac to be taken  occasionally in
compound  scordium or  some other distilled  water, through the
whole course of the disease."
  For common drink he prescribed milk and water, or the  white
decoction,  with crumbs of bread, or posset-drink; and where there
  Vol. II.—Q q 
306
HJEMATICA.
[CL. III.—OR. H.
 was much debility, he allowed a beverage of half a pint of sack to
 a quart of spring-water.   The ordinary food was panada or mutton
 broth.
   Dr. Sydenham's sheet-anchor, however, was  his own celebrated
 liquid laudanum, the vinum opii of the London College, but with a
 much larger proportion of the narcotic: though  he only preferred
 the liquid to the solid laudanum, as purified opium was then called,
 because of the grater conveniency of dividing it into doses.  So at-
 tached was be 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 sufficiently
 opened.
   Rhubarb  has been objected to by Dr. Cullen and other modem
 practitioners on account of its astringency : but  Dr.  Fordyce has
 advocated its employment as clearing  the primse viae better than
 any other purgative.  Its astringent effect, however, is sufficiently
 guarded against in Dr. Sydendham'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
 excite a general relaxation,  and make a revulsion  towards the
 surface.  By taking off the spasmodic constriction, it acts, indeed,
 indirectly as a laxative,  and in this way is also of great advantage.
 But as its immediate effect on the bowels  is to constringe them, it
 may  be very much improved  by uniting  it with  small doses of tar-
 tar emetic, or Dr. James's powder ; or which, perhaps, in  the pre-
 sent  disease, is still better, with some neutral salt and ipecacuan, as
 in the admirable composition of Dover's powder.  And with these
 few alterations it would be difficult, perhaps, to improve  upon the
 plan laid 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
speed; and the sick room  be large, and freely ventilated.
* Sect. IV. Cap. III. passim. 
KE. X.—SP. II.]     SANGUINEOUS FUNCTION.               307
                        SPECIES II.


            DYSENTERIA  PYRECTICA.

                     Bysnitcrfc iFetar.

 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 PITRID 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 introvcrsam," " 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:

   u  Caumatodes.      The accompanying fever being a cauma.
   C Typhodes.        The accompanying fever being a typhus.

   In the  present day the latter seems to be by far the most common;
 and the description by Sydenham is a sufficient proof  that the fact
 was not  very different in his time.  And I am  hence induced  to
 believe, that it is chiefly in sporadic cases that the dysenteric fever
 is  a cauma; while in those  of epidemic or  contagious origin, the
 fever is of a typhous, or at least of a synochous character: of a mixt
 breed, with a strongly marked tendency to  run from a caumatic  to
a typhous type.
   The general symptoms of this species are  drawn up,  like those
of  the last,  with so much correctness and strength of colouring by 
308                     HJEMATICA.            (CL. Hi.—OR. U.

Sydenham,  that we cannot do  better than  take them in his own
words.   Ihe 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 slated 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 attended1 with violent pains
and  sickness,  and,  if unskilfully treated, with extreme peril.   For
wben 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
 clo»e of  the  disease aphthae frequently affect the interior of the
 mouth, especially if the patient have been kept hot for a long time,
 and the  morbid material have been checked  in its  evacuation by
 astringents, the fomes of the disease not having  been first carried
 off  by purgatives; and  such aphthae generally foreshow imminent
 death.    If the patient survive these symptoms, and the disease
 prove lasting, the  intestines are progressively affected downwards,
 till  the malady reaches  the rectum and ends in a tenesmus. And in
 this case, contrary to what occurred during  the afflux of mucus,
 even the excrementitious stools occasion great pain in the intestines
 generally ; the feces in  their passage through them abrading the
 small guts, while the former evacuations only molested the  rectum,
 where  alone the mucus was formed and ejected."
   The epidemic or pyrectic dysentery of foreign  climates does not
 seem to differ essentially from the above:  for Dr. Sydenham ex-
 pressly states that  that  common to the African coast, on the return
 ot every autumn, was in his day of the same kind, and yielded to the
 treatment  adopted by himself as he was  fully  informed  by Mr.
 Butler, British Envoy  in that quarter:  while the history of the
 dysentery that raged among the British troops in Jamaica in April
  1780,  as given by Dr.  Moseley,  is nearly a repetition of the above
 symptoms : with  the exception that it appears to  have commenced
 something more in the form of a cholera,  with sickness at the
 stomach and copious purgings, and that its march 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
mariner; 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 ceneral 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 clusters of animacules, 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 all
 possible speed, and repeated, if necessary, without fear.  There is,
 nevertheless, no disease that rt quires the  exercise of a sounder
 judgment upon  this point than  dysentery :  for we have already
 observed that the fever,  if not typhus from the first, has a general
 tendency to pass into this type; and the intestinal inflammation is
 perhaps of the erysipelatus kind.   And  hence, unless the indica-
 tions for it are strong and prominent, this mode of cure had better
 not be ventured upon.

                     • Phil. Trans. 1813 and 181#. 
310
HJEMATICA.
[CL. ni.—OR. U.
   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 nausea should be maintained
by  a repetition of the medirine  for  some hours.   But I cannot
regard  such a preference as  the  result of  a sound judgment.
The relaxation that follows upon nausea* ing medicines is of the most
depressing kind ; scarcely any thing so much  exhausts the living
power; the languor hereL . produced  is intolerable, and sometimes
amounts to deliquium.  And hence, how serviceable soever such a
state might be in the high  ide 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 depressor already; and  stand in need
of rousing and strontr revulsive action, rather than  increased pros-
tration 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 everv part; and by urging
the circulation to the surface, and  promoting a copious perspira-
tion, 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 gencrally^nd 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 iis 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 obsolete.
Sir John Pringle's patronage of this medicine is fully justified by the
numerous and irresistible authorities  in its favour in the cases  of
dysentery, collected by him, and read before the  Royal Society;
and afterwards published  in the Edinburgh Medical Essays.*  It is
said to be uncertain in its operation; but this is an objection which
has been made by Henermann to all the preparations of antimony ;t
and to the present not more than to any of  the  rest: for it must be
admitted that the degree of their action depends very much on the
• Vol. V. Art. XV.
t Bemerkungen, &c. Band, I. p. 184. 
 I.E. X.—SP. II.]      SANGUINEOUS FUNCTION.              311

 state of the stomach,  and not a little on the idiosyncrasy.  It was
 long in the hands of  empirics before it found its way into regular
 practice; and the world  is,  or ought to be,  much 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 be moved, or rather where Uie object is not to ex-
 cite sickness,  it should be diminished to six grains; in which quan-
 tity it rarely excites nausea;  and upon the whole, in 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 alone;  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
 laudapum  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 sqii'-czcd 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 often 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 :  for as a
 hard  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 I
 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. 
319
HJEMATICA.
[CL. III.—OR. H.
  The best method, however, of employing opium in dysentery is,
by combining it with small quantities of ipecacuan and some neutral
salt, as in the preparation of Dr. Dover's powder, already recom-
mended under the preceding species. This may be given in a dose
of five grains immediately after the stomach and bowels have been
cleared, and continued every five or six hours till the gripings and
flux of blood subside, and the pulse becomes softer and slower;
which will generally  be effected  with considerable  perspiration in
twelve or fourteen hours; beyond which  period the sweating fit
should not be pressed at a single time.
  Much, however, of the benefit to be derived from Dover's pow-
der as a sudorific, depends upon its proper administration, and the
care taken to co-operate with its influence by a proper adjustment
of clothing. For this  purpose Dr Cullen lays it down as a rule that
it should be given in  the morning, when the ordinary sleep, or  term
of sleep, is over; " For sleeping," says he, " though not incompati-
ble  with, is  commonly not favourable to, sweating."  This,  how-
ever, would be, in many instances, to lose much time; and we must
always begin  as soon as we have it in our power.  There is more
importance in another part  of  Dr.  Cullen's course, that no drink
should be taken into the stomach till some degree of sweat breaks
out, lest the  powder should be thrown up  by vomiting.  Beyond
which  he recommends that the covering on the body  generally
should not be more than is merely consistent with the intention of
sweating; in many cases not more than is ordinarily made use of;
but that some considerable addition should be laid over the feet and
legs;  and that if the sweat should not, by these means,  extend to
the extremities, boiled bricks  or bottles filled with warm water
should be applied to  the soles of the feet: and further, that as'the
heat and perspiration advance,  if the patient feel himself too hot
and restless, whatever additional covering has been put upon the
body generally, and even a part  of what has been put upon the low-
er limbs, should be 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
effect 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-
vellant as any of those already noticed, but which we should not al-
ways recommend, nor find our patients disposed to carry into effect.
" Two dysenteric patients,"  says he, " in the same ward of the In-
firmary at Edinburgh, quarrelled  and whipped each other with
horse-whips a long time, and were both much better after it."*
• Zonoom. Cl. II. i. 3.19. 
GE. X.—SP. n.)
SANGUINEOUS FUNCTION.
313
  The only narcotic that has acquired any reputation in this com-
plaint, besides  opium, is  that species of  strychnos which is best
known by the name of nux vomica.  It was at one time in consider-
able use in Sweden and the north of Europe.  It is less astringent
than opium, but has a much more temulent effect on  the head.  It
was, however, chiefly employed, as we learn from Dr. Hagstroom,
as an anthelmintic, from the mistaken view of Linneus, 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,
however, asserts that he employed it with  success in doses of from
ten to fifteen grains given once or twice a-day.*
   If tlie 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 Ritcher does not  think the dis-
ease can be radically subdued,   He allows, indeed, of  purgatives,
when there is  evident proof of too large a secretion of bile; but
deducing his opinion from three distinct courses of epidemic dysen-
tery, he regards the bilious affection as merely accessary, and only
secondarily to be attended to in the cure of the disease. As a purga-
tive, moreover, he prefers calomel to rhubarb: contending that the
former, while it proves more powerful in removing the accumulat-
ed bile and correcting its acrimonious flow, operates at the same
time more gently  than any other cathartic; while  rhubarb, under
these circumstances, is even a dangerous medicine, and sure to in-
crease  the irritation.  This view of the case, 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  Ritcher himself employs it  in the latter stage of the
complaint, as combining the two desirable properties of being  a
mild aperient and  tonic.   In the less  violent cases of the disease}
he commences at once with his  diaphoretic plan, by a combination
of laudanum with small doses of ipecacuan or antimonial wine; and,
■where there is  much fever, he  premises an emetic: and, in this
  • K. Lazarettet i Stockholm, &c. p. 17.—Abhandl. der Schwed. Acad, de*
IVissench. Band. XXV.—Rese, Diss, de Nuce VomicS. Jen. 1788,
  Vol  II.—R r 
314
HEMATIC A.
LCL. III.—OR. If.
case, he also recommends that the  abdomen should have warm fo-
mentations or  a blister applied to it, or be well bathed with cam-
phorated Or some other rubefacient liniment.
  If, however, the local symptoms, and particularly the flux of blood
or bloody feces, or mucus, continue in spite of  this treatment, they
must be opposed by some astringent or tonic, as well as by a sedative
plan : for the debility alone which will hereby be produced may be
sufficient to threaten the life, even though the fever should diminish.
And in this case great benefit has  been obtained by the mineral acids
.ti 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:  someiimes 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
ihe 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 modeof 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 Helmot, or the aqua regia of
later chemists, the nitro-muriatic acid of the present day, in doses
of two drops of the  nitric, one of the muriatic, and ten minims of
laudanum, intermixed with infusion of roses  or  that of the more
powerful astringents logwood,  catechu, and gum  kino.   I have
employed this medicine with peculiar advantage, not only in dysen-
 teric, but in many other loosenesses, and hemorrhages of the bowels,
 increasing the proportion of the acid or the laudanum as the urgency
of the symptoms require.
   When, however, the  thirst is  considerable, and acidulous drinks
 are called for, we may for this purpose use the sulphuric acid as the
 most grateful;  though in this  case the citric acid  will usually be
 preferred, and the patient  may  be allowed to exercise his  choice.
 Yet the one or the other of  the above compounds  should  be con-
 tinued without any alteration in  consequence of such beverage.
   As the disease declines there  will often be found  a very conside-
 rable degree of debility and a  chronic diarrhoea, with occasional
 discharges  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 
OE. a—SP. n.]     SANGUINEOUS FUNCTION.
315
  this situation, and especially where the disease has assumed a highly
  malignant character, many of the bitters of the Materia Medica
  may be resorted to, in connexion  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 simaiouba 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 intesti-
 nal debilities, I am pleased to see it taking a  stand in the Materia
 Medica of the London College.
   The cinchona is of more doubtful efficacy.  It will be greatly
 beneficial where the disease has assumed an intermittent or a putres-
 cent character, but it is apt in many  idiosyncrasies  to irritate the
 bowels, and when had recourse to must be closely watched.
   Of the nerium antidysentericum of Linneus, formerly in high re-
 pute, under the name of conessi bark,  as an invigorating bitter and
 tonic in the present and all other debilitating complaints of the ali-
 mentary canal,| I cannot speak from personal trial; but it  seems to
 have fallen into  oblivion too suddenly, and deserves  a further in-
 vestigation.  The virtues of columbo  need  not be enlarged upon;
 they are known  to every one in  the present day: and under every
 form this medicine will be found a  powerful auxiliary in the hands
 of a practitioner§ who has  judgment  enough  to seize the proper
 moment in which it ought to be employed in the progress of dysen-
 tery.
  In conjunction with this process, the very great tenderness of the
interior of  the larger intestines, from erosion or abrasion, will often
  •  Lewis's Mat. Med. in verbo.  Beaum£ Journ. de Med. LVH, 507. Quarin,
in Dys. Malign. Animadvers.  Gooch's Gases, &c. p. 421.
  f  Mat. Med. Vol. II. p. 79.
  \  Monro Edin. Med. Essays, Vol. III. Art iv.
  §  Percival's Essays, II.  Hist de la Society do Medicine, p. 340.1776. 
31$
HJEMATICA.
[GL. III.—OR. II
for a long time demand peculiar local  Attention;  and demulcent
or bland oleaginous injections, as the infusion or oil of linseed, or
olive-oil with a little wax and soap dissolved in it, together with a
grain or two of opium if there should be much pain (the whole not
to exceed three or four ounces in quantity,) will often be found of
great assistance, as well in affording present ease, as in forwarding
the expansion of a new  cuticle.
   In long protracted and chronic cases, lime-water drunk freely has
occasionally also proved useful.  The coat of the  intestinal canal
is here, however, sometimes very considerably thickened and indu-
rated. And in such cases the best  remedy we can have  recourse
to is mercury.  Houlston recommends such a course to be persisted
in to salivation.*   Libavius commenced his mercurial plan  with
mercurial ointment.t 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 XI.

                     BUCNEMIA.



OlENSE, DIFFUSE, INFLAMMATORY SWELLING OF A LOWER EXTREMITY j
  USUALLY COMMENCING AT THE INGUINAL GLANDS, AND EXTENDING
  IN THE COURSE OF THE LYMPHATICS.

This genus is new to nosological classifications : but it is necessary,
in order to include two diseases which have hitherto been regarded
by most writers as totally unconnected, and treated of very remotely
from each other; 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  Bucnemia, from Gov, a Greek augment, probably derived
from the Hebrew#3 or nj?3 "to  swell,  augment,  or tumefy," a
• Observations on poisons, &c,
f Hornung, Cista, p. 2.
t Rat. Med. Fart HI. p. 277. 
GE. XI.—SP. I.j      SANGUINEOUS FUNCTION.              SIT

particle common to the medical  vocabulary; and the Greek noun
WW, " crus," or, " the leg," literally, therefore, " bulky or tumid
leg."



                        SPECIES I.


             BUCNEMIA SPARGANOSIS.

                  Dueqjcral  £umtti=2tco.

 PHE TUMID LIMB PALE, GLABROUS, EQUABLE, ELASTIC, ACUTELY TEN-
   DER *, EXHIBITINGTO THETOUCH A FEELING OF NUMEROUS IRREGUAR
   PROMINENCES 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 hate regard-
 ed the latter as a species of elephantiasis, and arranged and de-
 scribed it accordingly.  In the present author's first  edition of his
 Nosology the ordinary arrangement was so far yielded to as to place
 the two species remotely, though a distinction between elephantiasis
 and the tumid-leg was strongly enforced.
   The tumid-leg of lying-in women has been described by different
 authors under a variety of names, as phlegmatia dolens, phlegmatia
 lactea, ecchymoma lymphatica,2Xio\ 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 <rirxe.yx*>,
 " to tumefy and distend ;" tumeo 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.  Diseases of the Puerperal state. 
 3J8                     HJEMATICA.            [CL. HI.—OR. II,

 whence the French practitioners call it to the present day, after Pu-
 zos, depot laiteux, or lait 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 of 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 tumour 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 on the subject, Mr. White, Mr.
Trye, Dr. Ferriar, and Dr.  Hull,  concur in  deriving this disease
from some affection of the lymphatics of the distended side, though
they 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; 
GE. XI.—SP. I.]      SANGUINEOUS FUNCTION.
319
Dr. Ferrlar 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 distention.   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 pueperarum, 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
symptoms 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- 
820
HJCMATICA.
[CL. 1U.—OR. U.
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 mercurial 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

              ffumifc&eg  of  Ittjot Qtlimattn.

THE TUMID LIMB HARD, LIVID, AND ENORMOUSLY MIS-SHAPEN : SKIN AT
  FIRST GLABROUS, AFTERWARDS THICK, SCALY, AND WARTED : SUC-
  CESSIVELY BULGING AND INDENTED : OCCURRING CHIEFLY IN TROPI-
  CAL CLIMATES.

This species is intended  to comprise 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 dal-fil or
elephant leg of the Arabians, being so denominated from its livid,
tumefied, scaly, and mis-shapen appearance.  As the Arabic dal or
daul-fil is literally elephantiasis or elephant-leg, and as the Greeks
distinguished 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 fourthorder of the
present class: and the confusion has, in a considerable degree, de-
scended to our own times, insomuch that many writers of the present
day continue to jumble the elephantiasis, or elephant-/^, of the Ara-
bians, with the elephantiasis, or elephant-*£m, of the Greeks, and
to describe them as a common affection, though no two complaint" 
  GE.XI.—SP.II.j       SANGUINEOUS FUNCTION.              «^,

  can be more unlike ; the former being a mere local malady, pro-
  duced  accidentally, and  confined  to  the  individual who  labours
  under it; and the latter a constitutional disease,  in every quartet
  hereditary, and in  most quarters contagious.
    The Arabians, however, had the disease called elephant-skin, thp
  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 dis-
  order he professes to be the immediate subject of his pen, as a pe-
  culiar branch of leprosy, merely varied by its  commencing in the
  feet, instead of in any other part of the body:  and, carrying on the
  confusion, 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 their
 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 meh down, and run  together as if made of wax., The slight-
 est affection of the diseased parts occasions  a  discharge of blood,
 which,  however, is  commonly easily put a stop lo.  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  immovable:  at the same lime that, in many in-
 stances, 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 opi-
nion it is not a disease of those climates, but was introduced, and con-
• G. G. Schillingii de Lepra Commentationes, Svo. Lugd. Bat. 1776.
f Edin. Med. Comm. Vol. V. p. 264.
Vol. II.—S s 
322
UA.MATIGA.
[CL. 111.—OR. II.
tinues to be supported there by an importation of negro slaves from
the coast of Africa.
  For a distinct and more correct account of this species, we must
turn to the writings of Dr. Hillary* 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 u 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 obtain 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
physicians, and very common in that country. It is also indigenous
to  the Polynesian isles, where it takes the  name of  yavu-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
irritable, and especially  so when affected with inflammation in tro-
pical climates.  The blood-vessels,  and particularly  those of the
surface, are here also greatly  relaxed;  and hence the skin, instead
of maintaining the paleness of the first species, very soon  becomes
suffused with a deep red or purple  hue; while the saburral fluid,
that exudes from  the cutaneous exhalants,  concretes, as its  finer
parts fly off,  into  rough  or sordid scales, and  the skin itself becomes
enormously thickened and coriaceous.
   The effusion is usually preceded by  a febrile paroxysm induced
by the  glandular  inflammation  just  noticed; and which,  from ihe
first, discovers a  tendency to recur, though often at  irregular pe-
riods, 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. 549. 4to edit. 1799. 
HE.  XI.—SP. H.]     sAM.UINF.OUS 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 quickly 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 lo:ig
continued rigor, that it almost  proved fatal.   So strong, however,
was the patient's desire of relief,  that, with the intermission of one 
224
IL-LMAl'ICA.
LCL. III.—OK. M.
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 several weeks.  At
the end of a month he was very greatly improved, and shortly after-*
wards the whole of the symptoms had nearly left him.*
  Amputation of the affected leg has sometimes been made trial of,
but apparently without any success.   Dr. Schilling informs us that
in some a locked-jaw takes place about  the seventh  day from  the
operation, which is soon followed by tetanus,  and ends  in death;
that in others, fatal convulsions ensue immediately;  and  that those
who survive the operation have wounds  hereby produced that will
not heal;  while the disorder,  still tainting the constitution,  often
seizes on the other foot.!  And in this last assertion he is corrobo
rated by one or two cases related by  Dr.  Hendy.!
                      GENUS XII.

                      ARTHROSIA.

                 gCrttrolar  Xnflammattou.

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

Arthrosia is a term derived from x^oa,  " to articulate," whence
arthrosis, arthritis, and  many other  medical  derivations.  The
usual term for the present genus of diseases, among the Greek
physicians, was athritis, which would have been continued without
any change, but that, for the sake  of simplicity and regularity, the
author has been anxious  to restrain the termination itis to  the dif-
ferent species of the genus empresma that have just passed in re-
view before us; whence arthrosia is employed instead of arthritis4
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:

  * Vhil. Trans. Vol. LX1I.
  t G. G. Schillingii de Lepra Commentationes,  8vo. L>ugd. Batav. 1776,
  i Or foe 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:
Bergius, that they are convertable affections.  White-swelling, in
one of its varieties, is now  uniformerly 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 correctly
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 I have at this moment under my care a
lady in her forty-ninth year, of delicate health and gouty diathesis,
who is labouring under a severe and decisive fit of gout in the foot,
which is prodigiously tumefied  and  inflamed, and  has been so 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.  The 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 Mr. Hunter had,  at this  time, drunk no  wine for four or  five
years, and allowed himself but little sleep at night.
• Rat. Med. Part. IU. p. 122—137. V. p. 420. 
326                    HJEMATIC'A.             [CL. Ill—OR. II.

  Arthrosia, therefore,  as a genus, may, I think, be fairly allowed
to embrace the following species:

1. ARTHROSIA ACUTA.             ACUTE RHEUMATISM.
2. ---------- CHRONICA.         CHRONIC RHEUMATISM.
PODAGRA.           GOUT
4.    ' ■      HYDARTHRUS.       WHILE SWELLING.
                       SPECIES I.

                 ARTHROSIA  ACUTA.

                    Slcutc a&hcumatfsm.

 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:
 i  Artuum.                     Pan felt chiefly in the joints and
   Articular rheumatism.          muscles of the extremities.
 G  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 of  the side affected,  or
                                 an elongation of the limb.
 9 Thoracis.                     Pain felt chiefly in the muscles of
   Spurious pleurisy.              the diaphragm,  often  produc-
                                 ing pleurisy of the diaphragm.
  The common remote cause of articular rheumatism, as of all the
 other varieties, is cold or damp applied when the body  is heated;
 though it may possibly be  produced by any other cause of inflam-
 matory fever, where the  constitution has  a peculiar tendency to  a
rheumatic action. This tendency or diathesis  seems to exist chiefly
 in the strong, the young, and the active ; for,  though it may attack
 persons of every age and  habit, thes* are principally its victims.  We
may hence, as well as from its  symptoms, prove rheumatisn 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 pans 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 distention with greater
difficuliy.  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  connot say from  his own prac-
tice; but it is the remark of a physician who was not accustomed to
form a ha>,ty 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 lo take place ;! 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,
 anti 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
 ankles, 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. Comraun. U. 19.
  + Comment, de Morbis quibusdam. Art. 79.
  I Morgagni, De Sed. et Caus. Morb. Ep. LVD.  Art. 90. Med. Comment.
Edinb. Vol, IV- p. 198. 
328
HJEMATICA.
[CL. HI.—OR.tl,
   The fever is generally accompanied with copious and clammy
 sweats; but the skin still feels tense and harsh ; nor does the sweat
 issue freely from the immediate seat of pain.  It seems to be an in-
 effectual effort of the instinctive  principle or  remedial power of
 nature to carry off the complaint;  for it is by this evacuation alone
 that 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 any part of it during the perspirable stage.
 The exacerbation, which regularly returns in the evening, increases
 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 arc
 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 thai there is  no  constitution invulnerable to
 the attack of rheumatism, although the young and the vigorous fall
 most frequently a prey to its tortures.  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 worthwhile 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- 
QE. XII.—SP. I.]     SANGUINEOUS FUNCTION.               S29

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,! 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 acute rheumatism, " I hold  the bark to be absolutely improper,
and  have  found it to be manifestly hurtful, especially in its begin-
ning, and in its truly inflammatory state."!  Yet in direct opposition
to such feelings and such assertion, confirmed by numberless testi-
monies of equal weight, 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 time of writing, he had  for fifteen years  relinquished
bleeding in favour of the bark; and that during this period of time
he had not above two or three patients out of several  hundreds for
which he had prescribed it;  and  had rarely met with any instance
of a metastasis, a very common occurrence 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.
  f Clinical Experiments, Histories of Dissections, 8vo. Kdm. 1780
  * Mat. Med. Part II. Ch. II. p. 100.
  § On Fever, Dissert. Ill
Vol. II.—T t 
330                      HjEMATICA.            [CL. Ill—OK. 11.

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 I have rarely met with suc-
cess : and have often, like  Dr. Cullen, had reason to think it injuri-
ous.  Is  it that in certain habits, as those of great weakness and irri-
tability ; in certain districts, as in low and swampy grounds, charged
with the fomites of intermittents; or, in certain temperaments of the
atmosphere, as in sudden  successions  of wet and sultry weather, the
bark has a  tendency even  in acute rheumatism,  as we know it has
in spasmodic affections occurring in weakly  constitutions, to take off
tension and rigidity as well as to take  off relaxation: and thus to in-
duce a healthy tone by letting down the action of muscular fibres,
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 generally,
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 ofthe hip-joint was called among the Latins ischias,
 from iT^ies, the Greek term for hip;  which was afterward corrupt-
 ed into isciatica or sciatica,  a word that has occasionally found its
• Clinical History of Diseases, 1805. 
GE. XII.—SP. I.J     SANGUINEOUS FUNCTION.
331
way into the dramatic poetry of our own country, as in Shakspeare's
Timon,

                        The cold sciatica
            Cripple our senators, that their limbs may halt
            As lamely as their manners.

  This variety, at its  onset, has sometimes  been  mistaken for  a
phlegmonous inflammation of the psoas muscle.  But in the latter
there is, from the first,  less tenderness to the touch, but much more
enlargement, and the pain shoots higher into the loins.  In sciatica,
indeed, the whole limb, instead of continuing to swell, soon 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 dupli-
catures or appendages, it exhibits many of the symptoms of pleu-
risy or  peripneumony.   But here,  also, as in every other  case of
rheumatism, we have much greater tenderness upon pressure than
in phlogotic inflammation, while the pyrectic  symptoms  are consi-
derably less, and  often  highly disproportionate  to the pain  that is
endured, so that the  degree of pain and of fever becomes no  mea-
sure for each other.
  There is this peculiar character belonging to the three last varie-
ties, that though they  are less disposed to wander generally than
the first, they  are peculiarly  apt to run into each other's  proper
field, and to affect the  stomach, which, in consequence, becomes
sometimes enormously flatulent and expanded, with a sense of heat
like that of a burning coal.  If the back or loins be pressed hard to
obtain ease, the pain is transferred  to the side  or stomach; and if
the pressure be followed up into the side, it returns  with violence
to the back or hips;  or the breathing is impeded, and can only be
carried on in an erect position.*
  Generally speaking, however, in these three varieties, the dis-
ease is less erratic than in the first, and particularly in lumbago and
sciatica.  And  it is owing to this fact, that the loins  and the hip,
from having been more uniformly affected, are often so  long, even
after the complaint has subsided, before they recover any degree of
tone,  so that the  patient is frequently a cripple for many months;
and still suffers from  chronic rheumatism, which in these cases
proves no uncommon sequel to acute.
  Local applications, which are rarely of service in the  first or ar-
ticular variety,  as the pain is so apt to wander from every joint to
every joint, may in  all these be frequently employed with more
advantage; and where  general and copious bleeding  may be con-
traindicated, leeches  or cupping have often  afforded considerable

        » Cartheuser Diss, de Lumbagine rheumatica. Fr. 1755.
          *cheid,  Diss, de Lumbag. rhenmat. Arg. 1704. 
33 e
HjEMATICA.
[€L. HI—OR. II
relief.  The compound camphor liniment, as an elegant rubefacient,
is perhaps more frequently employed  than  any other medicine o*
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 friction 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 excites a gentle
moisture, both by its perpetual friction and the  stimulus of the tar
with which it is so largely impregnated.
   Blisters seem rarely to be of all the advantage we should expect;
but  the vesication from sinapisms succeeds better than that from
cantharides, probably because it operates with a 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 horse-radish.  The tartar emetic ointment has been
also frequently made use of, and sometimes with success: it gives a
permanent irritation, but the exulcerations  it produces frequently
prove foul and troublesome.   Dr. Percival  of Dublin, in a manu-
script note to the volume of Nosology, tells  me that, in sciatica, he
has 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.

                  dThronfc llnetunatfsm

PAIN, WEAKNESS, AND  RIGIDITY  OF  THE  LARGER JOINTS AND SUR-
  ROUNDING MUSCLES; INCREASED BY MOTION; RELIEVED BY WARMTH ;
  LIMBS SPONTANEOUSLY,  OR  EASILY GROWING COLD J  FEVER AND
  SWELLING SLIGHT, OFTEN IMPERCEPTIBLE.

Concerning the proper position, and, in some sort, the nature of
this disease, Dr Cullen confesses  himself  at a great loss.   In his
Synopsis, he arranges it as a sequel of acute rheumatism, and so ex-
plains it in his definition: vet he  gives  it  a distinct name; that o* 
GE. Xll.—SP. II,]   SANGUINEOUS FUNCTION.               C3S

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 disposed is at full liberty, he
adds, as to any objection of his own.  Yet in his First Lines he takes
a different view; and perhaps a more correct one than either of the
above.  Chronic rheumatism, instead of being a mere sequel of acute
rheumatism, as 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, u pro sequela
 rheumatismi acutirheumatismum chronicum dictum semfierhabeo"
 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, it is 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 fixed 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 up-
 wards of a hundred strokes in a minute in the acute species, the
 skin in the chronic species seldom exceeds its natural temperature,
  and the pulse is rarely quicker than eighty strokes ; the joints are
  less swollen, and of a pale instead of being of a  reddish hue, cold
  and stiff, and roused with difficulty to a perspiration; and always
  comforted by the application of warmth.
    The  disease continues  for an  indefinite period, and  sometimes
  only terminates with the life.  The affected joint  is occasionally
  debilitated  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 
j 34
H-XMATIC'A.
[CL. HI__OR. II
  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 vtry valuable addition.
    Most of these are, also, powerful diuretics; and as acute rheu-
  matism is best and soonest removed by warm sudorifics, so chronic
  rheumatism seems to be chiefly  relieved, and, indeed,  radically
  cured,  by diuretics of a like  stimulus.  Hence,  horse-radish and
  garlic are often found serviceable; and turpentine still more so;
  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 certainly
 more entitled to a trial.   In our own country, however, practition-
 ers have far more generally had recourse to cataplasms of ammonia,
 cumin, 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 of electricity, or roused it by the
 stimulus of  the voltaic trough.  And, when every thing else has
 failed, the patient is usually advised to try what, perhaps, it would
 be better that he should try at first, the mysterious agency of the
 Bath  waters.
   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, I had almost said so fashionable a remedy,  in consequence of
 the warm and confident recommendation of Dr. Percival.
   This offensive material is procured by the process of putrefac-
 tion,  and appears to  derive its stimulant 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 
GE.X1I.—SP. 11.]     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 I have never  tried in this complaint.  It  is
strongly recommended by Dr. Bardsley,*  and, in his hands, it seems
often to  have succeeded.  It may be commenced in doses of ten
drops, and gradually increased to double this quantity, and should be
united with a few drops of laudanum if it  sit uneasy on the stomach
by itself.
                       SPECIES III.

               ARTHROSIA PODAGRA

                           (Gout.

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 PARTS ; 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 obscura,
" clear  or cloudy drops or defluxions," according to the external
appearance.   Rheumatism and gout were alike attributed  to the
same origin : and as the terms rheuma and gutta were used in medi-
cine synonymously, botb 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.
" We have still," says Dr. Parr, " the treatise of Carpinati publish-
ed at Padua in 1609, De Gutta seu Junctuauum dolore;" but the
term may be traced to Valescus de Tarenta, who wrote his Com-
• Medical Reports, 
336
H.EMAT1CA.
\ML. HI.—OK. 11.
 mentary early in the fifteenth century; and Schneider in his Libcv
 Catarrhorum  Specialissimus, published at Wittenbergh in 1664j
 usually denominated the sixth volume, and peculiarly scarce, de-
 scribes 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 far 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, there is no disease concerning the nature
 and  treatment of which physicians are so little agreed: so  that to
 this moment it  constitutes perhaps the 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 ?  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 dia-
thesis is, in some instances, original, and in others  hereditary  or de-
rived.   There are many persons in whom this complaint makes its
appearance, 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. Apo. 
GE. XII.—SP. HI]    SANGUINEOUS FUNCTION
337
supposed to originate.  There are others, who, though exhibiting a
life of great regularity and abstemiousness, afford proofs of the same
diathesis in occasional paroxysms to which it gives rise:  and such
persons are  almost always  capable of tracing  it hereditarily.   For
the diathesis having once established itself, keeps its hold on the
system, and is propagated from race to race whatever be the man-
ner of life of the individual, or the general state of his constitution;
though  there can  be no question that those descendants are most
subject to its paroxysms who indulge in the  excesses that laid its
first foundation.
  A gouty diathesis thus produced,  like a phlogotic  diathesis, to
which in  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 disturb-
ance of a very different kind, as well as affecting very different or-
gans, according to the temperament, constitution, manner of life, or
some incidental circumstance of the individual where the general
health is sound, fixing on one or more of the extremities in the form
of a peculiar but very acute inflammation that runs through a regu-
lar paroxysm and gradually subsides: and, where the. health is in-
firm, and the general form debilitated, exciting great  derangement
in some internal organ or  set of organs, and particularly those of
digestion; or shifting from one form to another, and thus proving
itself under every form to be the same disease, and laying a foun-
dation for the three following varieties:—

* Regularis.             Pain, swelling, and inflammation of the
  Regular fit of gout.       affected joint considerable and acute;
                           continuing for several days, often with
                           remissions  and  exacerbations;  then
                           gradually resolving, and leaving the
                           constitution in its usual  or improved
                           health.
/3 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 affections of the joints.
y Complicata.             The disease fixing on some internal or-
  Retrograde ; recedent;   gan instead of on the joints; or sud-
    misplaced  gout.        denly transferred from the joints after
                           having fixed there; producing in the
                           internal organ affected, debility or in-
                           flammation, according to the state of
                           the constitution.

  The predisposing cause of a gouty diathesis, when it first forms
itself in  an individual, it has already been observed, is plethora with
entonic condition of the vessels. And hence in its Origin, as well as
  Vol. II.—U  u 
3$b
HAEMATIC A.
[CL. HI.—OR. Ii
in the symptoms it evinces under a regular paroxysm, gout makes
a near approach fo various other inflammations of which we have
already treated; and is more disposed to  show itself where it has
been transmitted hereditarily in men of robust and large bodies, of
large heads, of full and corpulent, and especially gluttonous habits,
or whose skin exhibits a coarser surface in consequence of being
covered with a thicker rete mucosum.  Castration is said to act as
a general  preventive; but on 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.
  Such is a  brief history of the origin, hereditary transmission, and
effects of the podagric diathesis; which must be distinguished from
the paroxysms to which it gives rise, and which constitute the only
manifest indications of its existence.
  The paroxysms of gout are excited by certain occasional causes,
some of which are obvious  and  some  doubtful, or altogether  un-
known ; but, without the co-operation of these, the gouty diathesis
may remain  unnoticed or quiescent in the body for years,  or 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 in 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
paroxysms in different individuals are often produced  by intoxica-
tion, or excess of eating; violent emotions  of the mind, particularly
the depressing passions, as grief and terror; sudden exposure to cold
when the  skin is in a state of perspiration; wet applied to the feet;
great labour of the body; severe application of the mind, especially
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, and from a full to  a spare, diet; excessive
evacuations 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 
 *v.E. XII.—SP. III.]   SANGUINEOUS FUNCTION.               339

 sional causes just adverted to, may be doubled.  Such an  opinion,
 however, has prevailed among the vulgar as well as among many
 of the more learned in most ages.  Thus, among the Greeks, it was
 a popular belief that Attica was the hot-bed of gout, as Achaia was
 of ophthalmy; whence Lucretius,

        Atthide tentantur gressus, oculeique in Achxis finibus.*
        Gout clogs the feet in Attica, the sight
        Fails in Achaia.

 And thus, too, in more recent times, we are told that China,t  and
 even some of  the German provinces, are exempt from the  attack
 of gout, while in  our own country it exercises an almost irresistible
 sway.   The last assertion is true enough,  but we are not driven to
 the variable nature of our climate to account for the fact.
   Thus far we can proceed safely respecting the general pathology
 of this Proteus-disease.  But the  moment we enter upon the field
 of its  proximate cause, we are bewildered in a hopeless labyrinth,
 without a thread  to guide our entangled footsteps amidst the grow-
 ing darkness.   There has, indeed, been no want of attempts  to ex-
 plain the  subject, but thus far they have been attempts alone—in-
 genious 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 $ 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 ihus despumated has, in various instances, prov-
 ed contagious, and  this not  to man only, but to other animals as
 well: thus M. Pietsch informs us  that he  has known dogs affected
 with the same disease by licking the ulcers that have followed upon
 a fit of gout accompanied with chalk-stones.
   Dr. Cullen has taken great pains in a series of nine consequtive
 arguments to prove the error or absurdity of most of these opinions ;
 and then proceeds to establish his  own; which consists in regard-
 ing the proximate cause of a gouty dialhesis as dependent upon a
 certain vigorous and plethoric slate of the system ; and the proxi-
 mate cause of a gouty paroxysm as produced by an occasional loss

  • De Her. Nat. VI. 1117.
  + Le Conte, Nouvelles Memoires sur l'dtat present de la Chine. Pans, 1*96.
  I Schaffer Vers. II. p. 176, who denies it: and Degner De Dysenteria, who
maintains it. 
340
HJEMAT1CA.
|CL. 111.—OK. II.
of tone in the extremities, often communicated to the whole system,
but especially lo 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  Cullcnian
doctrine of fever to the disease before ub,  and  is chargeable with
the same incongruity ; for here, as in fever, the stage of strength or
increased  energy is made  to  depend upon the  stage of weakness ;
as the weakness or loss of tone is made dependent upon a peculiar
vigour and plethoric state of the system.  There is, indeed, no
great difficulty in conceiving how  loss of tone  may follow upon
excess of energy; but by what means recovered energy is  to be a
result of  loss of tone, is a problem of more laborious solution.
   I have dwelt the longer upon this subject, because it involves a
very essential point in  the remedial process, and one which has
rarely been  sufficiently attended  to:  before 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 arc 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 ihe life, to  show  itself most commonly in  January or
February; but I have known  it occur so often towards the close of
the summer, and in the autumn, and have attended so many patients
who have never had it except  in the latter seasons, that  the  rule
does not  seem  to  be any  way  very well  established.  The  first
attack is usually  in one of the feet, most commonly about  the bail
or first joint of the great toe ; it commences at night or during the
night, and there is sometimes, though not always, a slight  horror,
succeeded by a hot stage.   The local pain  and  swelling increase in
violence,  the joint assumes a  fiery redness, and the whole body is in
•Pract. of Phys. Part l. B H. Ch. XIV. DXXXIII.
t Butler, Nadere out dekkinge der menschelyke Waters. Harlem. 1697.
* Eph. Nat, Cur. Dec. I. Ann. 111. 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 it3 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 commencemtnt 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 Ibis 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 or^an 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
HjSMATICA
[CL. 111.—Oft. li.
   It is a remarkable fact, hitherto indeed little dwelt upon and alto-
 gether unaccounted for, that as the system  advances in years  and
 debility, and every other  secretion progressively fails, that of
 calcareous  earth seems to increase.  Hence the bones of aged
 persons are more fragile and apt to break upon slight concussions;
 and the arteries and various other parts  become ossified or loaded
 with nodules of lime-stone; and where a 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 bursae
 mucosae, and renders motion  uneasy or destroys it  altogether.
 The lime-stone, moreover, as it hardens, acts as a foreign irritant
 to the distended  integuments, and produces, what simple inflam-
 mation of the gout never does, ulcerations and an offensive  dis-
 charge.  For the same reason nephritic calculi are often a sequel of
 gout when it has assumed a chronic form; and the children of gouty
 parents are said  to be hereditarily disposed to  both  complaints,
 some of them exhibiting a podagric and others a nephritic affection.
  Thus  far we have followed up the  progress of a regular attack
 of gout in a constitution otherwise healthy and vigorous.  But  the
 same diathesis exists in systems of delicate and infirm health, and
 where there is a  want of  sufficient  energy lo work  up a fit of
 inflammation, and throw it off at its  appropriate outlets.  And in
 such case, as soon as it becomes roused into action by any of  the
 causes of excitement already enumerated, it constitutes the second
variety, assumes the guise of various other diseases, as  dyspepsy,
 hysteria, hypochondrias, palpitations of the heart, vertigo, hemi-
 crania, with several  modifications of palsy or  apoplexy.   The
stomach  and bowels, however, form  the chief seat of  affection;
the  appetite is fastidious or destroyed;  a spasmodic  stricture of
painful oppression is felt in  the epigastric region, or the stomach is
distended almost to bursting with flatulence; nausea, eructations,
vomiting, and all the symptoms of indigestion follow, and are alter-
nated with severe colic or  costiveness.  In the mean while the
disease shows itself at times, in one or more of the joints in slight
and fugitive pains, as though making an ineffectual effort to kindle
up  a paroxysm  of  proper  inflammation, but which there is not
energy enough in the system to accomplish; whence the articular
pains cease almost as soon as they appear; and the visceral derange-
ment is renewed: sometimes slowly subsiding after a continuance
of several weeks; and sometimes wearing out the entire frame and
terminating  in abdominal or cellular dropsy.
  It sometimes happens, however, that while the general constitu-
tion of a podagric patient is tolerably sound, one or more of the
internal organs form an exception to the general rule, and are less
healthy than the rest.  And as upon an excitement of gouty inflam 
GE. XII.—SP. HI.]   SANGUINEOUS FUNCTION.               S43

mation  in a gouty habit, the inflammation seizes ordinarily upon
the weakest part of the body, it makes its assault upon such organ
rather than upon the hands or the feet;  or, if it  commence in the
latter, is readily transferred to it;  constituting the third of the va-
rieties before us, and which has usually been called retrograde or
misplaced gout.  And if the  general system should, at the same
time, be below the ordinary tone of  health when the paroxysm is
thus excited by the force of some occasional cause, the organ affect-
ed may  evince great languor and painful inertness, as in the second
variety, rather than acute inflammation, as in the first.   The  sen-
sation in the stomach,  instead of being that of a fiery coal,  is that
of a cold lump of lead; in the head it changes from maddening pain
to oppressive  horror,  in which the  patient suddenly starts from
sleep almost as soon as he has began  to doze, from the hideousness
of the ideas that rush across the mind and form  the distracting
dream.
  The fit is sometimes transferred to the bladder; in which  case
there is acute pain at the neck of  the organ, 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 re-
gular fit of the disease.
  It was formerly the belief, as we have already seen, that a gouty
paroxysm was an effort of nature to throw off from the constitution,
and  thereby restore it to a  state  of  perfect  health, some  peccant
matter forming the proximate cause  of the distemper;  and it 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 this
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 diseas,e to  some  internal organ of 
344                      HiEMATTCA.           [CL. HI.—OH. 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 lhan 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
sepel the inflammation from the extremities to some more import-
ant organ:  while opium, though it affords relief in present parox-
ysms, occasions them  to return 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 opinion
of Sydenham, Cullen, and every other physician, hastens on another,
renders its  intervals shorter, and its duration  longer; and  progres-
sively saps  all the energies both of mind and body, and  renders life
itself a burden; it is of serious importance to inquire whether this
fear of a repulsion, however well founded in some instances, is not
allowed too generally; whether it be not possible to draw a definite
line between the form of the disease in which it ought to operate,
and that in which it ought not  ? and  whether in the latter case we
may not derive all the benefit from a full use of a reducing process,
which is obtained in other inflammations, accompanied with a like
degree of constitutional vigour?
   From the history of this disease, as it has already  passed before
us, we may draw this general corollary  : that the specific inflam-
mation of gout, or whatever other morbid character it may evince,
when once  excited by some occasional cause into action, has a pe-
culiar tendency lo 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 Lines of the Practice of Physic, Aph. D1.X1X 
GE. XII.—SP. Ill]   SANGUINEOUS FUNCTION.
345
  In healthy constitutions the weakest parts are the extremities;
and hence, in such constitutions, these are the parts, as we have
already seen, in which the gout uniformly opens its assault.  Here
it commences, and here it runs through its course, seldom migrat-
ing,  or when it does migrate, only passing from one extremity to
another; as from foot to foot, or from one of the feet to one of the
hands; and limiting itself to these quarters, because they are the
weakest parts of the system: though, as just  observed, in a tho-
roughly sound constitution such  migrations are not common.
  In unhealthy habits, however, the  extremities are not the 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.
  These are rules which we cannot  loo 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 refrigerant means employe
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.—X x 
346
HiEMATlCA.
[CL. Ill—OH. H.
surface of the body with cold water; and in small-pox,  not  only
purge freely, but expose the patient to the coldest atmosphere of
the winter-season.
  In weakly habits, or idiosyncrasies, or incidental debilities  of
particular organs, 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 indefinable 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 
 GE. XII.—SP. Ill]   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
 ihe 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 w?.s 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 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
IUEMA l ICA.
[CL. III.—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 effusion.  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 ihe use of a car-
riage has prevented the excess of fatigue which he had hitherto of-
ten undergone ; but from a love of walking he still frequently in-
dulges in it; and for about the last three years he has had neither
gout nor any other complaint to interrupt his usual career of good
health.   During the  preceding paroxysm, the appetite being good,
the bowels regular, and the pulse not much quickened, he made use
of no collateral means, nor ever found the use of the  cold  water
productive of the least inconvenience :  though he has occasionally
been sensible of a gradual creeping through the system of the pecu-
liar aura just adverted to, which may  perhaps be called the aura
podagrica, but which constituted no unpleasant sensation.
  The practice before us, however, is by no meansof modern inven-
tion, however it may  have become a subject of warm controversy in
the present day.  An active eyacuant 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 Lusitanusf in 1641, to Kolhaasi 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.%
  But  this treatment, I am ready to admit, has often been employed
rashly and sometimes with great and even fatal mischief.   It ought
never to be ventured upon, except, as already stated, where the con-
stitution is decidedly sound and vigorous ;  for though I subscribe
to much of Dr. Kinglake's therapeutic plan, I cannot agree with him
that a gouty paroxysm is a merely local affection.  The treatment
before us should be limited to those who are in full vigour, and per-
haps entony of health ; and is especially to be avoided  where the
stomach^is dyspeptic, the lungs asthmatic, the heart subject to pal-
pitation, the head to nervous pains or drowsiness ; or where  there
is any known disability in any other important organ.
* Aphor. Sect. V. p. 25.
f De Medicorum Princip. Historic, Lib. 1H. Amsterd. 1641.
* Baldinger, Neuer, Mag. Band. V. p. 521. 1788.
§ Abhandlungen und Beobachtungen.  Berl. 1789.
II De usu nivis medico, 1661, 8vo.
"I Observ. Pbysico-med. Hamb, 1691, 4to. 
GE. XII.—SP. HI.J    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 same 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 gouly paroxysms he  asserts that  it occasions  the fits to
return with  additional fury.    Yet it should never be  forgotten,
that it is  a law in  the history of gout,  and one to 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 ihirritant; 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
HJEMAT1CA.
[CL. III.—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 any other quarter.
   To obtain the first intention, we have to strengthen and even sti-
 mulate the system generally  by warm  tonics and a generous diet,
 and above all things to take 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 paroxysms 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
 breathing 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 paryoxsm,  and  render the stimulant antidote
less availing.
   Most of the preparations  of ether contained in the current Phar-
 macopoeia of the London College, may be  employed with benefit in
 the variety  before us, and particularly in  that icy coldness of the
 stomach, accompanied with the numbness of the limbs and a  rapid
palpitation of the heart, under which  it occasionally exhibits itself.
Phosphorus itself has sometimes been ventured upon in this  case, 
GE. XH.—SP. III.]    SANGUINEO US PUNCTION.
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 large doses may be given without
procuring sleep, or showing any of those deleterious effects that in
other cases appear  from much  smaller quantities  given.  All this
appears from the  practice now well known in tetanus, mania, small-
pox, gout, and  syphilis."!
   In retrocedent gout the same plan is to be pursued  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 disease are of as much
importance to be  attended to as its paroxysms : and here, also, the
mode of management  under the first form should differ essentially
• Physical and Literary Essays, Vol. II. Art. XH.
f Mat. Med. Part II. Ch. VIII.
t Mat. Med. Part II. Ch. VI. 
r.52
HJEMAT1CA.
[CL. 111.—OR. II.
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 fermented liquors altogether; but where
the sufferer has passed considerably beyond the zenith of life, and
the luxuries of the table have become habitual, his  ordinary fare
should be reduced or diminished rather  than entirely commuted.
And  in every change it is better to  proceed slowly than to rush
rapidly  from one extreme to another:  since nothing has so great a
tendency  to prepare the internal organs for gouty paroxysms, as
such sudden and violent transitions.  The bowels should be kept in
regular  order, and the hour of rest be early.
  A  due  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
atonic 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
Caelius 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
• Vol. I. Class I. Ord. I. Gen. V. Spec. 7. p. 100. 
13E. XH.—SP. HI.]    SANGUINEOUS FUNCTION.              353

 service it appeared to have rendered him,  is formed for the most
 part of the very same ingredients, modified either from the Greek
 writers, or Dr. Sydenham's prescription; though it is a simplifica-
 tion of the latter, by omitting several of the articles that enter into
 its composition, one or two of which had better  be retained.  In
 this reduced form it consists of equal parts of the five following ma-
 terials, finely powdered and intimately commixt: birthwort, gen-
 tian, germander, ground-pine, and the tops and leaves of the lesser
 centaury.  The dose is a drachm taken  fasting every morning  for
 three months;  after which it is to be reduced to three quarters of
 a drachm for  three months longer;  then to half a drachm for  the
 remainder of the year: and after this the same dose is to be conti-
 nued every other morning only, through the  next twelve  months;
 by which time it is presumed that a cure will be accomplished.
  The real effect of this and  similar medicines is  very doubtful,
 and the doubt arises from the gradual mischief 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 gradu-
 ally under complaints more distressing and fatal than the gout itself,
 as dyspepsy, lowness of spirits, and dropsies of almost every part,
 especially hydrothorax, ascites, and anasarca.
  Now it is possible that the regimen alone may have produced
 the good, where good has been experienced, and the gouty diathe-
 sis the evil, 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 at well as tonics, and some of them direct narcotics, there
 can be no question that they have a tendency to prevent local  in-
 flammation in a vigorous and robust frame, as well as in a relaxed and
 debilitated.  But tonics and even sedatives are as little called  for
 in the former condition of body as they are demanded in the latter;
 and may perhaps prove as mischievous  in the end as a sedentary
 life combined with prodigal eating and drinking.  There must in
 both cases be too great an excitement of the sensorium,  and secre-
 tion of sensorial fluid, and consequently too great an exhaustion of
organic power with a perpetual tendency to torpitude in every part
of the system.  In both cases fuel is added to fire, and the constitu-
tion, if not bursting into open  inflammation,  seems  to be  equally
consumed by a secret and smothered flame. The gouty diathesis is
no doubt fed and confirmed;  and as regular fits of gout are kept  off
probably by the sedative qualitv of the bitter tonics employed,  we
  Vol. II— Yv 
354
HJEMATICA.
[CL. HI.—OR. II.
have reason to expect indigestion, low spirits, dropsy, and all the
effects of high living, although the latter is relinquished.
  I have thus endeavoured to account for the very different  effect
which tonics and especially bitter tonics, appear to produce in dif-
ferent cases of gout, and to justify the caution with udpich they were
given by the  Greek physicians, as well  as by laterpathologists  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 were 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 supposes  all bitters to possess a deleterious quality of some kind
or other; and that in all gouty persons, or at least he makes no dis-
tinction, they have a power of 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 a 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 tolerably entire.  Soon after  finishing the course of their
medicine  they became valetudinary in  different  shapes, and par-
ticularly were much affected with dyspeptic, and 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. XH.—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  pro-
duced  by a continuance of tonic  medicines.
   The subject, however, requires to be further examined into  by a
more accurate classification of gouty patients  who may be put under
the influence of medicines of this kind; and I throw out the  hint
for this purpose.  Yet that a  persevering course in bitter tonics
does not uniformly prove in any way injurious to those who engage
in it, is, I think, demonstrable from the daily use of table-beer in
almost 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 everyone 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 fitfvt
' Mat. Med. Part H. Ch. II. 
356
H^MATICA.
|CL. HI.—OR. H„
'EAAEB'OPOY of the Greeks was a different plant from either the
white or black hellebore of modern dispensatories.
  The  favourite specifics  of the present  day, M. Husson's Eau
medicinale, and the vinum colchici, or wine of meadow-saffron, in-
troduced in the current Pharmacopoeia of the London College chiefly
upon  the  authority and  recommendation  of Sir Everard Home.
The exact components of the former are kept a secret; though its
basis is well known to be either the one or the other of the above
plants, most probably the meadow-saffron.  The effects of the Eau
medicinale and of the colchicum-wine do not essentially differ;  for
after taking about  sixty drops of  either the pulse becomes slower,
and at  length sinks, in  about 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.  If the
dose be in a small degree in excess,the symptoms aresnycope, 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 ef-
fects have followed from the use of even a  common dose.   So  that
these preparations seem  to be rather stronger drugged than the
celebrated 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  sys-
tem through the medium of the stomach.   It is possible that the
colchicum may act by a specific power on the peculiar inflammation*
of a regular fit; yet, as other intestinal irritants have occasionally
produced a like effect, and particularly the gratiola officinalis (hedge-
hyssop) and ranunculus Flammula, the disappearance of the parox-
ysm may also be ascribed  to a transfer of action to the stomach and
intestines.  Generally speaking, specifics operate by a secret and in-
explicable power, as the bark in intermittents, the vaccine virus in
shielding the constitution against small-pox, and mercury in syphi-
lis ; for though  a ptyalism gives proof  that the  system is impreg-
nated with the last, there are  few  practitioners so attached to the
Cullenian doctrine in the present day as to contend that the vene-
real virus is carried off  by the  salivation, since we are perpetually
beholding  it carried off under the influence of mercury without any
salivation whatever.

                * Phil. Trans. 1816.  Art. XII. XHI. 
GE. XII.—SP. 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
employmen' of such violent means be not greater than the tempo-
rary good obtained by the suppression of the inflammation ? and I
do not think that either the Eau medicinale or the colchicum-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 be tried except in the first variety of gout, or where
the system is firm and healthy, and  the disorder shows itself  in a
regular fit.  And as it is highly desirable, for reasons already stated,
to restrain  the violence of the paroxysm, shorten its duration, and
carry it off as soon as possible, the use of the one or the other of
these medicines may be judicious  so long as the system  is able to
recover  itself with speed from  their influence, and  provided the
patient limits himself to the smallest dose that will answer the pur-
pose.
   Yet these medicines, from too little attention to their real  effects,
and from a mistaken idea that they are a specific  for gout under
every form, have not been confined to the entonic variety, but have
been very generally employed also in the second and third varieties
as well;  in which the system, and particularly the digestive organs,
are in a state of chronic debility, and the inflammatory fit, 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 hereby render the system  more open to all the miseries
which gout is so perpetually entailing.  And hence the reason of the
very general complaint among those who have tried these remedies,
that, although they remove the fit at the time, they shorten the in-
tervals, and render their frames more obnoxious to relapses.
   The subject must not be quitted without a brief glance at Dr.  Bal-
four's proposed mode of treatment, which consists in the use of com-
pression and percussion alternately applied  to the  inflamed gouty
joint; as they are applied in like manner to parts labouring under
acute rheumatism or any other kind of inflammation.  The opera-
tor is directed to seize the aching foot forcibly, by grasping the ball
of the toe in his right hand, and gradually to increase the pressure,
and continue  it till the impetus of the vessels has 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 I have never tried, for I have never been able to summon
fortitude enough to  propose  the addition of a remedial torture to
that already endured from the disease ; nor do I think I have ever
attended a palient who would have consented to the advice if I had 
ass
HAEMATIC A.
ICL. III.—OR. If
given it.  The direct object is to overcome the inflammatory action
by constringing the vessels; but this effect is more readily obtained,
and in a far easier way, and with quite as little risk, by cold water.
If in the course of  the compression the inflammatory action do not
soon yield, it  should certainly be relinquished: for a violent re-
action will accompany the resistance, and the inflammation be great-
ly augmented.  I have seen one or two striking examples of this on
applying the same method to inflammations of other kinds. A young
woman 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 preserved  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-
demics:.  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 not
show itself for nearly twenty years.  We  are  told  in some of the
foreign journals of like cures being effected by eating sour cherries.
And, as astringent  tonics are often  as useful as  bitter tonics, it is
possible that the gouty diathesis  has, in some instances been check-
ed or subdued by acids of various kinds, though we should be often
deceived if we  placed any dependence upon them.
                      SPECIES IV.

           ARTHROSIA  HYDARTHRUS,

                      2^hftc=SuicUins.

TENSE, PERMANENT, COLOURLESS SWELLING, CHIEFLY OF THE LARGER
  JOINTS : INFLAMMATION SLOW, AND DEEP-SEATED :  PAIN FIXED AND
  SEVERE : IMPERFECTLY SUPPURATIVE : FEVER A HECTIC.

This inflammation, like that of rheumatism, attacks the larger rather
than the smaller articulations.  Yet, as the joints are uniformly the
seat of its assault, and it runs  through its course without the produc- 
GE. XH.—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 scrofulous 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:

     x Entonicus.                  Entonic White-Swelling.
     ? Atonicus.                   Atonic White Swelling.

   The first variety is the rheumatic white-swellingof Mr. B. Bell,
 who  has treated of the  disease very fully and very judiciously in
 his work on ulcers.*  It occurs, indeed, as  he remarks, most fre-
 quently in young plethoric people in whom the rheumatic diathesis
 is predominant: or rather  that firm  elasticity of health and  fibre,
 which, upon the application of accidental causes, gives rise to rheu-
 matism as well as to the present variety of hydarthrus: and on this
 account the epithet of  entonic is preferred to that of rheumatic.
   The causes I have stated to be chiefly strains, and other  exter-
 nal injuries to the- larger  joints, as  bruises  and  luxations:  but,
 like rheumatism, it is also frequently excited by a current of cold
 damp air.   The pain is diffused, the swelling considerable from the
 first, and the inflammation, on dissection, is found to originate and
 be  chiefly seated in the synovial  membrane and surrounding liga-
 ments of the joints: though, according to Mr. Brodie, it sometimes
 commences in the circumambient cellular substance.t   The intu-
 mescence feels tense and elastic,  but  there is little discoloration at
 any time.   From  the  increased and  morbid action of the vessels
 there is not much effusion of coagulable lymph, but a considerable
 surplus of synovial fluid, not less than four ounces of which was dis-
 charged in a case related  by Dr. Simson, by making an opening
 through the integuments and synovial membrane.   The 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,
{- Pathological and Surgical Observations on Diseases of the Joints, 8vo. 1818. 
360
H.EMAT1CA.
[CL. HI.—OR. H.
 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 patella,  generally on the
 inside, but sometimes on the opposite, and could get no ease till by
 chafing the joint with his hand he made it disappear.   Upon a re-
 moval of the preternatural bone by an incision and an evacuation of
 the  synovia, the patient appears to have been instantly relieved;
 for,  contrary to the  advice of  Dr. Simson, he shortly afterwards
 mounted his horse and rode home through a distance of two miles
 and  in a frosty night.  But he had soon reason to repent of his im-
 prudence for he caught cold, and suffered excruciating pam 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
 blended 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 abridgment 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 separate from each other.
   As the  bone does not readily become  affected nor even  the
 periosteum, the joint may in this manner often be preserved  and
 restored to use.  A  very considerable degree of stiffness, indeed,
* Edinb. Med. Essays, Ar0l. IV. Art. XX. 
 GE. XH.—8P. IV.]    SANGUINEOUS FUNCTION.             S61

 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 ampu-
 tation.
   The atonic variety commences, and consequently is chiefly seat-
 ed, in the bone itself of the affected joint, originating, as Mr. Brodie
 observes, in its cancelli.*  The pain,  therefore,  is  here more cer-
 cumscribed, and appears to shoot almost from a point, and the swell-
 ing  is inconsiderable.  The pain, however, though more limited,
 is very acute, and increased by the least attempt  at motion ; so that
 in this case  also, the muscles being always kept quiet and in a bent
 position, a stiffness of the joint is readily superinduced.
   The  inflammation proceeds more  slowly than  in the entonic
 form, but it produces at length  the  same effect;  the tumour ac-
 quires the same  elastic feel; varicose veins appear on the surface,
 and  collections of matter take place in different  parts of it.  The
 minute and separate abscesses burst one after another, and discharge
 an ichorous or cheesy and purulent fluid,  and small exfoliations of
 the subjacent bone are occasionally thrown out at the openings.  This
 variety constitutes the scrofulous white-swelling of Mr. Bell; and
 if not always confined to scrofulous 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 scrofulous 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."f
   The occasional causes are sometimes  those of  the preceding va-
riety; but the disease more generally commences without our being
                * Patholog. and Surg. Observ.
                t On Blood, &.c. p. 391.

Vol.. II.—Z  z 
362
HJiMATICA.
[CL. HI.—OR. H.
able to trace any occasional cause whatever: and is far more dispos-
ed than the preceding to terminate in a fatal hectic.
  The practice is most disheartening, and the prognostic most me-
lancholy.   No course of medicine promises much success ; while
even a removal of the limb may only lead the way to an appearance
of the disease in some other joint.  The pain may be soothed with
opium; and local stimulants have been found useful in an early stage
of the disease,  or where the diathesis is  not  decidedly scrofulous.
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 mir iated 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 describ-
ed, the tumour, when  in  an incipient state,  seems to have been
quite as favourably acted upon by the attack of some unforseen ex-
anthem, as small-pox or miliary eruption, as by any  topical  plan
whatever.^
  • Heister, Wahrnehmungen, B I.  Wendt, Nachricht von dem Institutum
clinicum.  De Meza, Anhang zer Strack  Abh von der Petetschenkrankeit.
Plater, Observ.  L. III. p 704.  Bromfield's Observations.  Kirkland on the
present state of Surgery.   Percival,  Med. Com. Edin. VII. 67
  -j- Proett, Versuche einer Chirurg Gesillschaft in Kopenhagen. Baylie, Pract,
Essays.  Michaelis, in Kichter, Chir. Bibl. B. V. p. 113.   Stoerck, von der
Schwarzen Kuchenschelle, p. 82.
  * Med. Trans. Vol. I. p. 104. 
     CLASS III.

HJEMATICA.
                        ORDER III.


             EXAN THEMATIC A.

                     Krujitfte Jpebevs.

   CUTANEOUS eruptions essentially accompanied with fever.

The term Exanthemata, among the Greeks, from e£«vde#, " 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
eruplions) produced alone by  specific contagion : " eruptiones  a
contagione specifics, ortae ;" while Dr. Willan has still more lately
narrowed it so as to include those eruptions only which fall within
the meaning of the English term rash, whether febrile or not fe-
brile.
   The two last senses of exanthemata or exanthematica, are new
and singular.  Dr. Cullen,  however,  has not followed up his own
suggestion into his own classification;  while Dr. Willan has not al-
ways continued strictly true to  his  own views and  definition, as I
have observed in the running comment introductory to the present
order in the volume of Nosology  to which the reader may turn, for
a fuller examination of this subject at his leisure.
   The term, therefore,  in the present work, is employed  in its
common and current  sense, so as  to include all cutaneous eruptions
in which fever exists as an  essential symptom; whether accompa-
nied with or destitute of contagion;  which last  is a doubtful and
perhaps inappropriate ordinal  character.  Doubtful, because we
cannot very precisely tell where to draw the line; and inappropri-
ate, because it is a character that applies to diseases of very differ-
ent kinds, and that are scattered over the  entire classification, as 
364
HEMATIC A
[GL. in.—OR. HI.
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 blennorhcea 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  ihe  part  of animal ferments,
converting the different fluids into  their own nature, exciting the
commotion of fever, and bt ing 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 on this ad-
 mirable economy of nature, and of illustrating it from the course
pursued in inflammations of every kind ;f  which to obtain this bene-
 ficial end, often wind their way outwardly through a multiplicity of
 superincumbent organization, instead of opening into some momen-
 tous cavity in the interior, from which it  is perhaps only separated
 by a thin membrane.  But there is no part of pathology in which
 this  display of a final cause, of an operative  intention admirably
 adapted to the end, is more striking than in the order of eruptive
 fevers.
   It is by means of the fever that the disease works its own cure;
 for it is hereby that a general determination is  made to the surface,
 and the morbid poison is thrown off from the  system.

       • See especially Class II. Ord. II.   On inflammation, p. 161.
       t On Blood, Inflammation, &c. pp. 236, 450, 467. 
CL. III.—Oil. HI.)     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 occasion-
ally  occur in inflammations, and require the  art of medicine for
their correction.
   When a febrile poison,  producing a cutaneous eruption is gene-
rated, or has been conveyed into the blood, a small degree of fever
is sufficient to throw it upon the skin; and if it exceed the  proper
extent, the specific virus will be multiplied, and the fever itself may
become a source of real danger.  It was formerly the practice to
encourage the fever by cardiacs,  a heated atmosphere, and a load of
bed-clothes, from an idea that we hereby  solicit a larger  flow of
morbific matter  from the  interior to the surface.  The fact is un-
questionable ; for be the exanthem what it may, the skin will hence,
in almost every  instance,  be covered with eruption.   But it did not
occur to the pathologists  of those times, that the morbid virus was
an animal ferment, capable of multiplying itself by accessories; and
that heat and febrile action, beyond a very low medium, are among
 the  most powerful accessories we can communicate. And hence the
 advantage of the modern  practice of applying  cold 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 Ihe 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,          [CL, IU.—OR. HI.


                         GENUS I.


                    ENANTHESIS.


                     Rash lEpautficm.

ERUPTION OF RED, LEVEL, OR NEARLY LEVEL PATCHES J VARIOUSLY
  FIGURED; IRREGULARLY DIFFUSED; OFTEN CONFLUENT;  TERMI-
  NATING IN CUTIOULAR EXFOLIATIONS.

Tiie term enanthesis is derived from the Greek iv " in, intra," and
xvOca," floreo,"—" efflorescence from within or from internal affec-
tion."  Whence the term  stands opposed to exanthesis, which,  in
the present system,  constitutes a genus under the sixth class, and
comprises such efflorescences as are merely superficial or cutane-
ous, and not necessarily connected  with  internal or constitutional
affection.  Enanthesis is here, therefore, used to express fever ac-
companied with rash, the latter word being employed in the broad-
er of the two senses assigned it by  Dr. Willan, as  importing  red,
irregular, confluent patches, whether simple, as  in the case of scar-
let-fever, compounded of papulae, small acuminating elevations of
the cuticle, not containing a fluid, as in the case of measles; or ex-
isting in the  form of wheales, as in that of nettle-rash.
  And hence enanthesis, as a genus, furnishes us with three spe-
cies :

    1.  ENANTHESIS ROSALIA.      SCARLET-FEVER.
    2. ----      ■ RUBEOLA.      MEASLES.
    3.----------URTICARIA.   NETTLE-RASH.
                       SPECIES  I.

              ENANTHESIS ROSALIA.

                     Scarlrt=iFeijrr.

RASH, A SCARLET FLUSH, APPEARING ABOUT THE SECOND DAY ON THE
  FACE, NECK OR FAUGES; SPREADING PROGRESSIVELY OVER THE BO-
  DY; 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. 
GE. L—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 has so mortal an aversion to the term, that he pre-
ferred the error of blending scarlet fever with measles, and of ar-
ranging the varieties of the two diseases under the common generic
name of morbilli, to  employing scarlatina.   De Haen appears to
have had nearly as great a dislike to it.* *Dr. Huxham, for a long
time, eluded the term by using febris miliaris rubra, or maligna,
for some of the varieties of scarlatina, and febris anginosa miliaris
for others :  Dr. Heberden has still more lately exchanged it for
febris rubra; and Thiery, in direct allusion to the original name,
calls it expressly mal de  la rosa ; Dr. Willanf continues scarlatina,
but thinks it necessary to apologise for its continuance.  " The de-
nomination scarlatina," says he, •' was first applied to this disease by
British writers : however offensive the term may be to a classical ear,
it cannot well be displaced, having found admission into all the sys-
tems of nosology. Another age will correct and refine the language
now used in subjects untouched by the masters of Physic."|
   It will not be the present author's fault if the correction, so ge-
nerally  called for in the case before us,  should  be postponed to
another age;  or the error complained of  be  chargeable on future
nosologists.
   In saying that " the denomination scarlatina was first applied to
this disease by British writers,"  Dr. Willan can only mean that it
was by British writers first applied technically, and introduced, as a
professional term, into the Medical Vocabulary : for the term itself
is Italian, and was long,  as a vernacular name, in use on the shores
of the Levant before it was imported into our own country.
   Scarlet-fever,  measles, and small-pox seem, indeed, equally to
 have reached us from  the East, and to be diseases of 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, rosalia, and even morbilli
evidently point to the school of Cordova, and lead  us to the Arabian
• Med. Contin. torn I Cap. VH
| Recueil Periodique. II. 337.
* Cutaneous Diseases, p. 253, 
363
HJEMATICA.
[CL. HI.—OR. HI
 or Saracenic physicians for our first account of them.   And it is not
 to be wondered at that in such accounts we should meet with some
 degree of confusion  and  many  inaccuracies; and should perceive
 that as measles were for a long time confounded with small-pox, so
 scarlet-fever 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 ronge-
 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,
 wbjlc the measles were denominated senapio?i.*  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 W7atson.
   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 :—
at  Simplex.                    Fever moderate, and terminating
   Simple scarlet-fever.            with the rash ; little prostra-
                                 tion of strength: slighty conta-
                                 gious.
& Paristhmitica.                Fever  severe ; throat ulcerated ;
   Scarlet-fever with sore throat.   rash later  in  iis  appearance,
                                 and less extensive; often chang-
                                 ing to a livid hue: highly con-
                                 tagious.
■ Observ. Med. p. 454. 
JE. I.—SP. i.]
SANGUINEOUS FUNCTION.
369
  Children are by far the most frequent subjects of both these va-
rieties, and communicate it readily to each other.  They are both
occasionally epidemic, and in this form occur most usually at the
close of the summer.  The anticipating symptoms are those of fe-
ver ; about the second day from which, in the first variety, nume-
rous specks or minute patches of a vivid red colour appear about
the face and neck : and within twenty-four hours a like efflorescence
is diffused over the surface of the body, and occasionally even tinges
the inside of the lips, cheeks, palate and fauces.   Sometimes the
efflorescence is continuous and universal; but more  generally on
the trunk of the body, ihere 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
pathognomic efflorescence  has appeared in a greater or less degree
in the evening.  On the fifth day the eruption begins to decline;
the interstices  widen, and the florid hue fades.  On the sixth the
rash is very indistinct, and is wholly gone on the seventh.
  The pulse, during the eruptive stage, is usually very quick and
feeble;  the tongue is covered  with  a whitish fur in  the middle,
often interspersed with scarlet points from  an elongation of the
turgid papillae; while the  sides of the  tongue are of a dark red.
The face is qpnsiderably tumefied; and there is great anxiety and
restlessness, with a sense  of tingling or itching in the skin, and
sometimes at  night a slight delirium.  Though the fever is in most
cases moderate, it sometimes runs high, but in the present variety
is rarely alarming.  In many cases, indeed, the eruption appears
and passes through its course with little inconvenience of any kind
from fever, itching, or restlessness.
   Sauvages, and Cullen, who has copied Sauvages's definition, re-
present the efflorescence as not taking place till the fourth day after
the attack.  Dr. Heberden, on the contrary, fixes it on the first or
second day :*  Dr. Willan, u usually on the second day."  This last
is the ordinary period, and as  such I have entered it in  the defini-
tion. It is obvious, however, that the interval observes some va-
riety : though not a little of the apparent difference may be ascribed
to the different stages of the disease in which a physician is first con-
sulted ; and his inability of fixing very accurately the commence-
ment of the febrile incursion.   Dr. Plenciz, on this account, pursues
a middle course, and avails himself of unallowable latitude; "About
the second or  third day,"  says he, "and sometimes later, the red,
unequal eruption, makes its appearance."!  Generally speaking, the
   * Med. Trans. Vol. HI. p. 397.
   | M. A. Plenciz, Med. Vindom. Tractatis de Scarlatina, 1776,
VoL. II —3 A 
378
HAEMATIC A.
[CL. III.—OR. an
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  \772, Dr. Clarke  tells us  that, where it began
with great vehemence, the eruption was often observed on the first
day : but commonly it did not make its appearance till the second
or third, and sometimes not till the fourth.
   We have seen that rosalia has  been often  confounded 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 is not  entirely absorbed by the time the
efflorescence subsides; and hence there is occasionally, though not
often,  an appearance  of  vesicles, sometimes  nearly empty, and
sometimes  nearly filled  with  a pellucid  fluid, according  as the
effused serum has been more or less carried off.   I have seen them
exhibit the semblance of minute chicken-pox; and they have been
thus noticed  by many writers,  particularly by  Di^ Rush,*  Dr.
Withering, and Dr. Plenciz: the last of whom compares them to
white miliary spots; and expressly s'ates that he observed them on
the sixth or seventh day from the commencement of the eruption,
chiefly in the hands and feet: in other words, at the time when the
turgid cuticular vessels had contracted and the efflorescence was on-
the decline.  On examination, he further tells us that they appear-
ed to be nothing more than cuticular elevations filled with  minute
bubbles of air.   More correctly, perhaps,  they  were  quite  empty,
the effused serum being carried off by absorption.t 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 II*. Ord. Exanth  Gen. VIII.
X Traotat  d>- Scarlatina
&>s4. Trans. Vol. V. Art. XI, 
«E.I.—SP.T.]       SANGUINEOUS FUNCTION.
a?i
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 £ 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 vellum pendulum palati will be found redder than natural, and
sometimes the uvula will appear to be a little inflamed, the pulse
being at this time not more than slightly disturbed, or flurried rather
than feverish.f   Dr. Willan asserts, that this takes place as one of
the first effects of the  contagion, and describes it, as "a dark-red
line extending along the  vellum pendulum palati and lower part of
• Buchbolz Tode Med. Chir. Bibl  Band. I. p  86.
f Dr. Sims, Memoirs of the Med. Soc. of Lond. Vol. I. p. "94. 
372
HJEMATICA.
[CL. 111.-OK. HI.
the uvula.*   Gradually, however, the tonsils become enlarged, and
exhibit a flor d paleness on their surface, which  extends over the
whole range of the palate, its velum pendulum, the uvula, and the
posterior part  of the  fauces:  the tongue assumes a  high  red
colour, the papillae  over  its entire surface 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 symptom';
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. 
 GE.I.—SP.I.J        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 debilitat-
 ing or sedative  rather than entonic;  and  condemns both purging
 and bleeding,  as  the pulse will not allow of these evacuations.
   In endeavouring still further to lay down the distinctive charac-
 ters of the two, he observes, after Dr. Fothergill,  that  the angina
 gangrenosa (sore throat with  scarlet-rash) usually commences in
 the winter or the spring, and chiefly attacks persons of  delicate ha-
 bits, as women and children; while the scarlatina anginosa (scarlet-
 rash 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 Newcastle-upon-Tyne in
 1778, seems to have reversed this rule in its most  essential point;
 for Dr. Clark, to whom I have just referred, and who have given a
 very minute and interesting history of this epidemy, telTsus 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. Clark therefore concludes that both these diseases
 proceed  from the same specific scontagion, and ought rather to be
 considered as distinct forms of the same exanthem, than as district
 affections.   It is accurately, also, observed by the same writer, shat
 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. Cotten 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 Fewer attended with ulcerated sore throat, &. 8vo. 1779. 
374
flJEMATICA.
[CL. m.—OR. III.
   The subject ought not to be closed without adding the following
note from Dr. Perceval's manuscript  comment on the author's vo-
lume of Nosology, already noticed on many occasions.  It adds a
high authority to the present arrangement of this form of the dis-
ease; and contains one or two remarks which  very agreeably dis-
play the observant tenour of the writer's mind.
   " Cynanche tonsilaris and maligna,  I consider with you as a spe-
cies of rosalia.   All have been produced by the same specific con-
tagion, 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 thiqp «
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, I have no data to determine.
   There are three modes  by which this, or indeed any other  dis-
order may become epidemic, using the epithet in  its general sense,
as importing a disease of  whatever sort that contaminates the at-
mosphere of a  district or neighbourhood.  It may proceed from a
specific miasm generated from local or accidental circumstances in
the atmosphere itself, as in the miasm of intermittent, and often of
remittent fevers; from a like miasm generated in the body of a sick
individual, and communicated to the atmosphere, as in typhus; or
from  a peculiar temperament in the atmosphere  predisposing the
entire population that inhale it to a common morbid affection.  Of
any specific miasm originating in the atmosphere, and producing ro-
salia, we have no proof whatever : but we  have abundant proof of
its issuing from the bodies of those who are sufferers under it; and
if I mistake not, of a peculiar temperament  or constitution of the
atmosphere in a  peculiar district or season, that predisposes to its
general production; for it often becomes common to many families 
 <*E. I.—SP. I.]       SANGUINEOUS FUNCTION.               ST5

 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
 unpredisposing atmosphere but slightly infectious: for, in treating
 of  the laws of febrile miasm which, under different circumstances,
 originates  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 received
 much more readily at some periods than at others.   Nothing is
 more common  than for a sporadic case of rosalia to occur in a fa-
 mily without communicating itself to the  surrounding  children,
 although  no pains may have been taken to keep  them separate;
 while a few month's afterwards it may possibly be received from a
 neighbour's house merely by an  incidental visit for a few minutes.
 In the former case  there was no predisposition in  the  habit to re-
 ceive the complaint;  in the other, the altered  state of the atmo-
 sphere has, perhaps,  produced such a predisposition in a very high
 degree, and prepared the way for the disease to become a very ge-
 neral epidemy.
  What this peculiar state of the atmosphere is has not yet been
 very accurately ascertained.  It does not seem to depend altogether
 upon the season ; though, commonly speaking, rosalia is more fre-
 quent towards the close of the summer, the common harvest-time
 of all debilitating diseases;  and we also perceive that it is usually
 checked, at all periods, by a cold, dry, and  bracing air, and hence
 is less frequent in the winter.   But, with these exceptions, it  has
 been found to range  as an  epidemy nearly equally from February
 to November;  and  sometimes through  the whole of this term with-
 out ceasing; or only slackening its career when a keen dry breeze
 has sprung up from the north or the east.
  We see, also, another peculiarity in this disease, and that it is in
its ordinary limitation to children ; and we see this character  ac-
company it equally, whether the disease be sporadic or epidemic.
Or, in other words, we behold the predisposing state of the atmo-
sphere observing the same restriction as the disease itself when it
operates independently of any such predisposition.   Adults, indeed; 
376
HJEMATICA.
[CL. III.—OR. III.
do not entirely escape, but their attacks are rare, and for the most
part less violent.
  The remote cause of rosalia, then, is a specific virus, or a speci-
fic miasm generated in the living body.  Of its occasional or excit-
ing causes, separate from the  predisponents just adverted to, we
know nothing.  It has sometimes  seemed to follow upon catching
cold, and at others upon a surfeit of the stomach ;  but as these are
perpetually taking place without producing such effect;  atid as ro-
salia has often occurred where  nothing of the kind could be traced,
we can lay very little stress upon such casualties.
  All exanthems  and nearly all fevers produce  an influence on  the
system that renders it less susceptive of the same complaint for a
certain period of  time  afterwards:  yet  the period varies from  the
plague, which exempts but for a few weeks, to the small-pox and
measles, which usually  extend the exemption to a lerm 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 indivi-
dual.  Scarlet fever seems to hold  a middle range.  It renders the
system far less susceptible,  and perhaps for several years;  but  the
influence, in  many individuals, wears off by degrees, and does not
protect the whole of a  man's subsequent life.   Yet, as rosalia is a
disease of infancy rather than of adult age,  it is not often that per-
sons suffer from it a second time,  though examples of such a  re-
currence 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, arid 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 
GE. I.—SP. I.)
SANGUINEOUS FUNCTION.
377
it is occasionally to be found after the mildest form of the disease;
but adds, that it succeeds chiefly to its malignant or worst species.
  The curative treatment needs not long detain us.   In slight cases
of the simple variety, we may say with Dr. Sydenham, that the dis-
ease hardly calls  for  medical assistance of any kind.  When.the
fever is mild, it forms, as we have already  observed  in  respect to
exanthems of all kinds, the  natural means of cure, by determining
the specific poison to  the surface.   An emetic may assist this deter-
mination, and has hence been almost always found serviceable; and
if the bowels be confined, an aperient may follow: but violent purg-
ing  will add to the irritation, and distract the remedial course that
is taking place.
  In the paristhmitic variety, the determination, instead of being
to the skin generally, is powerfully deflected to the throat and ihead,
and the fever is alarming from  its violence.  The therapeut  cin-
tention is here to counteract this morbid flow and redness of the fe-
brile action, always having regard to the nature of the fever as well
as to its severity.
  Bleeding is the most direct and obvious means of reduction;.but
it is open to the same objection as in typhus; 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 has recommended it still more lately.  Where the head
is manifestly oppressed from contagion, it may be risked as a mode
of local relief, and may be so far of  service: but it is a risk at all
times, and  ought by no means to form apart 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 1778, 8vo.
Vol. II.—3 B 
3Tfc
HJEMATICA.
[CL.III.—OR. II r,
any hypothetical good; and it will often be proper, as recommended
by Dr. Withering, to repeat it occasionally, as the foul and infarcted
state of the fauces may sequire.
  We have just observed that this distinguished physician prohibit-
ed purgatives as well as bleeding.   But in doing this he discovered
still  further the trammels of hypothesis ;  for while he conceived
that emetics tended directly to throw off  the matter of contagion
from the organ in 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 diapensed
with.  As aperients they  remove whatever acrimonious material
may be lodged in the intestines, and  as revellents they powerfully
recall all morbid determination from the head.  Calomel, as operat-
ing upon  all  the excretories, is commonly to be preferred to any
other cathartic, or may be conveniently combined with rhubarb.
  The great inquietude  that characterizes 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 dependence for this  purpose
must be upon Dr. Currie's bold and happy plan of employing cold
water freely.   Sponging will  rarely  be found sufficient, or rather
will rarely be found of equal advantage with affusion ; the flqid may,
indeed, in this case, be dashed against the patient till  the heat is
subdued, and the process be repeated as fast as it  returns.   The
refreshment is often instantaneous, and operates like a charm;  and
seems to show, as I had  occasion to observe formerly, not merely a
refrigerant, but an exhilarating power, as  though the water 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 paristhmitis; 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 recourse to the aurum fulminans,
as recommended by De Haen,f and speaks warmly of its  success.
Its design was to operate  on  the bowels and bladder, and it was
given in composition with  calomel,  rhubarb,  and squills.  I  have
never tried it, nor can I very  easily trace out the path by which
any benefit may be hence expected.   Wine and nutritious food may
• Tractat. de Scarlatina.
f Hat. Med. Continuata torn. I. Part. I. 8vo. Vienna. 
kiE. I.—SP. I.}        SANGUINEOUS FUNCTION.              379
be allowed, but  somewhat less freely than in malignant quinsy.
The convalescent state requires great care; and a damp, cold at-
mosphere should be especially avoided from the tendency to drop-
sical swellings.
                        SPECIES II.

              ENANTHESIS RUBEOLA.



 rash in crimson, stigmatised dots, grouped in irregular circles
   or crescents; appearing about the fourth day, and terminat-
   ing about the seventh ; preceded bt catarrh : fever a cauma.

 Of the earliest accounls we possess of measles  the  orgin  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:—

 *  Vulgaris.                   Rash slightly prominent, extend-
   Common Measles.             ing over the  mouth and  fau-
                                ces;  harsh, dry cough, inflam-
                                ed, watery eye.
 S  Incocta.                    Rash running its regular course,
   Imperfect Measles.            with  little  fever  or catarrhal
                                affection ;  affording no certain
                                security  against the common or
                                regular disease.
 7  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 variety 
380
H-KMATICA.
[CL. HI.—OR. HI.
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 is
not auxiliary to its diffusion, from its continuing to be merely scat-
tered ; yet possessing its ordinary principle of contagion, which only
appears to be less generally active because there is a less general
predisposition,  in  those  who have never undergone it, to be  acted
upon.
  It occurs  most usually in children, though no age is altogether
exempt from it.  As rosalia is  accompanied with a typhoid fever,
rubeola is accompanied with a catarrhal; and  hence, the  opening
symptoms consist of some  degree of hoarseness, with a harsh, dry
cough, and frequently uneasy respiration ; the eye-lids are tumefied,
the vessels of the conjunctiva turgid and inflamed; the cheeks  are
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 attend-
ed by so general a flush  as to be lost in them,  and to give  the ap-
pearance of  scarlet fever.  I have already noticed several signs by
which the 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 cough,
fever, and head-ache grow more violent; and the difficulty of breath-
ing,  weakness of the eyes,  and  indeed  all the catarrhal symptoms,
remain without any abatement till the eruption  has completed  its
course.
  Ip rosalia  we  have also  seen that the sooner the efflorescence
breaks forth after the febrile attack, the slighter and more favoura-
ble the disease.   The same occurs in rubeola. The ordinary period
we  have already stated  to be  the fourth day,  but it occasionally
appears on the third, when the  patient commonly escapes 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, Waarneemingen. 
GE. I.—SP. II.]      SANGUINEOUS FUNCTION.              381

till the twenty-first day: thus precisely rivalling the singular ano-
maly 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 aslighidiscoloration 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
rareiy 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  system, 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," says Dr. Perceval, in his manuscript comment on
the present species, " bex convulsiva yield the pas to variola, and then
resume its station."  In like manner consumption is generally sus?
pended during the entire 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 prqbat regulam ; they are so rare as
rather to  maintain than disturb  the law.f  Dr. Willan asserts that
he never  met with an  instance.  The  anomaly is  unquestiopably
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 gene-
ral, is necessary to a certain extent for the purpose  of throwing the
virus upon the surface; as inflammation in a certain  extent is ne-
cessary to produce healthy suppuration.   But a small degree of py-
rectic action is in both places  sufficient; for if this be exeeded,
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.
\ Eoberdiere, Rechercbes sur la Rougeole. Paris 1776 
382
H-EMAT1CA.
[CL. HI.—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, were measles prevailed," says Dr.  Perceval, in  comment-
 ing on  this species  as given  in the Nosology," typhous infection was
 introduced; hence  the variety * changed to  C."  It is highly proba-
 ble that some such accidental cause occurred in producing Sir Wil-
liam Watson's modification.
   Exposure to cold, so highly serviceable in small-pox, has, from a
 supposed analogy, been recommended also in measles by some rash
practitioners, and adopted by others.   All fair analogy, however, is
 against the practice: the fever in measles is directly catarrhal, and
 the analogy should be drawn, not from small-pox, but from  catarrh,
in 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, it 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 diarrhoea

      • Medical Observations, Vol. IV. Hoffman. Opp. torn. U. p. 67. 
GE. I.—SP. II.]
SANGUINEOUS FUNCTION.
383
proves the most favourable  crisis, and should be very cautiously
corrected.  And where it does not take place naturally, it may be
wise to imitate it by gentle laxatives.
  From a peculiarity of constitution, or some accidental influence
exercised over it at the time, the rubeolous rash is sometimes found
to run through its regular  course with little  fever or catarrhal
affection, as though it were a  simple cutaneous eruption, and without
appearing to afford an  immunity to the individual against a future
attack ; constituting our second species.*  This has usually been
called, and especially by the German writers, spurious measles; but
as it  occurs most  frequently when the genuine measles are epi-
demic, and is doubtless a result of their contagion, it is less properly
a spurious than an imperfect or unmatured 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  prepa-
ratory symptoms,  that they could hardly  say they  had been ill."
In this case the constitution is protected by a natural insusceptibility
of this desease; 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 in-
termixture of dark, discoloured, or petecchial spots from effused
blood, with the proper rubeolus 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
acrid serum from  the eyes, or from minute vesicles that sometimes
appear between the  patches of the rash.  Dr. Home, not being
able to obtain a contagious ichor from either  of these quarters,
drew blood from a turgid cutaneous vein 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
iruth  a very  unnecessary caution in a  disease that in its ordinary

           * New-York Medical Repository, Vol. V. Art. III. 
 384                      RKMATICA,           [CL. Hi.—OR. HI.

 range excites so little alarm ; and which leaves no blemish, like th«*
 Small-pox, on the skin.



                       SPECIES III.

             ENANTHESIS  URTICARIA.

                       &ettlr=fta*h.

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

 This, like the last species, is rather a troublesome than a dangerous
 complaint; though it is always attended 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
Writers.  The resemblance is close: but there  are characters by
which the two diseases may be  distinguished with tolerable ease
In nettle-rash the efflorescence is in scattered wheals with few  pa-
pula; ; in lichen, in scattered papulae with few wheals.  In the latter
 the itching is  more mordant and aculeate; the eruption instead of
 terminating in a few  days runs on to an intermediate 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
 defined outline, and no sensation of stinging.
• Medical Transaqfions, Vol. II. p. 173. 
 GE. 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 ihe 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 reoccupy their stations.   But all
 of  them  are of chronic duration, are  little accompanied with fe-
 ver; and  cannot be considered correctly as varieties  of the idio-
 pathic disease.  They  occur, however,  as such in Dr. Willan's
 treatise.
  A cooling regimen, and subacid diluents, with a free exposure to
 pure air,  generally succeed in effecting a cure of nettle-rash  with-
 out any other medical  treatment.  A gentle laxative or two  how-
 ever should be added to the domestic means : and if  the itching be
 very troublesome it may be often allayed  by the use of campho-
 rated vinegar. The juice of fresh parsley has the reputation of pro-
 ducing an equally  good effect; but  evaporation by  means of any
 other fluid applied to the itching parts would probably be found as
 beneficial.
  Dr. Willan describes a single case in which urticaria proved fa-
 tal.*  This patient was a man of about fifty years of age, who had
 impaired  his constitution by hard labour and intemperance.  The
 precursive symptoms were all  violent, and the sickness and languor
 were followed by fainting fits; and he had  great pain in the sto-
 mach, which was increased by pressure.  The fever was  consider-
 able, and soon attended with delirium.   While  the rash  was most
 vivid, his  internal complaints abated; but he gradually got worse,
 and died on  the seventh day.   Here, again,  however, the urticaria
 seems to have been only symptomatic.   It afforded him relief, and
offered the only  chance of a recovery.
                 * Cutaneous Diseases, p. 401.

Vol. II.—3 C 
386                     HJEMATICA.          [CL. in.—OR. HI.


                      GENUS II.

                      EMPHLYSIS.

                   ichorous 2£vatituem\

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

The term  emphlysis is derived from the Greek fjttor tv, " in, intra ;"
and 0Xvns, " a vesicular tumour or eruption."  Ex.<pxva is usually
employed among the Greek writers nearly in the same sense as^At/a».
In the  present system  it will be found employed somewhat more
strictly, and in opposition to ettipXvo; 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, if, 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  entitled eccritica.
  The genus emphlysis includes the following species :

 1. emphlysis miliaria.           miliary fever.
2.--------aphtha.            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.

                     aWltars  iPetoer.

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 
GE. 11.—SP. I.]
SANGUINEOUS FUNCTION.
387
 made its appearance, and another doubt among some pathologists
 whether it be ever any ihing  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 it 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: the) are afterwards
 opake and milky from absorption of the lnore 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 fit st 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.  Ploucquet seems to
 have intermixed all these as  well as pemphigus, and described them
 under  the  common name of  miliaria.!   In  like manner Gerike's
 dissertation on this disease is entitled De Morbo Miliari, alias pur-
pura dicto;\ and Juck's De Febre Milliari, 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-exanlhem, 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  petecchiae, and
 Huxham speaks of it as sometimes giving rise to them :|| an obser-
vation confirmed by a like statement of Boncerf:! and hence another
reason why it  has occasionally been  treated  of  under the term
purpura.

 • Sindner, Betrachtungen des Rothen und Weissen Friesels. Schweidniz, 1735.
 flnitia Biblioth. V. P. 564, 565.
 * Hal. 1733.
 § Erford. 1716.
 | Vol. I. passim.
 ? Hantesierk, Rescueil, II. p. 217. 
 388                     IIJEMATICA.           f6L. III.—OB. ffl.

   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  sometimes is 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 the 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 sympioms.  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 stages
 of a red and milky 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.f
   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 sabural  sweats of
 typhous fevers, in which it is only occasionally to be met with, and
 certainly less  frequently than in  other fevers.  M.  Planchon regards
has proceeding most frequently from obstructed perspiration, which
he lays down  as its common cause : and M.  Ti iller, instead of being
a result of  weakness, when in a symptomatic form, asserts that  in
various instances it proves critical.\
  • Rat. Med. II. p. 58, 169.
  f Dissertation sur la Ficvre Miliare, &c. Tourney, 8vo
  * Trille5 et Molina™  Epistolx mutus de vera esanthematum  Miliarum
differentia. 
GE. 11.—SP. 1.)       SANGUINEOUS FUNCTION.               389

  In few words, miliaria when idiopathic is an eruption accompa-
nied with a mild typhus, and a peculiar irritability of the skin. And
when the same eruption appears as a symptom of some other dis-
ease, it is probable that a like irritability of the skin has been pro-
duced by a course of saburral or acrimonious sweating.
  Of its remote or even exciting causes we  are utterly ignorant.
The siomach seems sometimes to be overcharged; cold in the feet
has been suspected ; and, as observed by M. Planchon, we  have of-
ten 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 defe-
dation of the stomach, an emetic should be given at the first. Cool-
ing 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 that he has frequently
prevented miliary eruption in lying-in women and others where it
might have been expected as a concomitant.  But where it has ac-
tually appeared, he adds to this regimen the use of tonic and an-
tiseptic remedies, particularly Peruvian bark, cold drink, and cold
air.
  Purgatives, however gentle, have been objected to by many pa-
thologists: 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 prac-
tice 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 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 lo check but to change the
perspiration: and hence, while  from  an early  period of this disease
he  has employed tepid ablution  or sponging, which is always highly
refreshing, he has given small doses  of antimonial powder with in-
fusion 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. Vol. LI. Art. XIX. p. 300, 
390
IL/EMATICA.
[CL. HI.—OR. m.
  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
wearing a shirt of coarse flannel or norse-hair.  And  hence Dr.
Darwin gives one example of miliaria, as he calls it, " produced by
the warmth, and more particularly by the stimulus of the points of
the wool  in flannel or blankets applied to the skin, which  by cool
dress, and bed-ciothcs without  flannel, soon ceased."  He has dis-
tinguished this affiction by  the name of miliaria sudatoria: but it
ought rather to be regarded as  a variety of intertrigo, or tret.
                       SPECIES II.

                EMPHLYSIS  APHTHA.

                          arnrusn.

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 xtttu  " accendo" " to burn or
inflame."   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:

* Infantum.           Appearing in infants soon after birth; and
  White thrush.         often  extending from the  mouth to the
                        intestinal canal; mostly with slight fe-
                        brile symptoms, and white sloughs.
" Maligna.            Accompanied with great debility of vascu-
  Black thrush.          lar 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 hectic 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
second and third  species some of the smaller blood-vessels arc also 
GE. 11.—SP. II.]      SANGUINEOUS FUNCTION.
391
eroded at the mouth, and hence the sloughs become livid or ulce-
rated.
   All the  varieties, therefore, occur under circumstances of con-
siderable 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.
Fiom  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 intes-
tines 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
disturbed,  though the stomach evinces acrimony, the pulse is often
a little quickened,  and the infant is rendered  fractious.  But in an
unhealthy  habit, when the food is innutrient, and  the frame weak
and atrophous,  the under-surface of the vessels ulcerate,  the ulce-
ration 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 powers,
 it seems necessary that it should come  into close union with the
 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 ulceration
 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 prims viae  by  a laxative 
392
ILEMATICA.
[CL. ni.—OR. III.
 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
 inviscating 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 fol-
 low  it up.
   The second variety, or elack 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.f   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.
f Sterblichkeil im Krankenbaus zu Rruchsal.
I Kaulin, von Erhaltung der Kinder.
§ Loco citato.
| Fontanus. Annal. p. 59. 
GE. II.—SP. 11.]      SANGUINEOUS FUNCTION.
591
   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 paliate; and our best paliatives 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 state 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 'he climate.
   " A slow hectic fever," says Dr. Latham, " with a pulse weak,
 and a little quicker than natural, marks  the commencement of ;his
 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 unfrequtmly
 dysentery, 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 exulceraiions ; 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.f  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  tonics should be
 had recourse to.  For the distressing irritation that often exists in
 the throat  and  rectum, Dr. Latham is bold enough to recommend
 gargles and injections of diluted litharge-water; the latter in com-
bination with laudanum.
             * Med. Trans. Vol. V. Art. VI.
             f Modern Practice of Phy8ic, p. 528
Vol. II.—3 D 
 394                     HJEMATICA.           [CL. HI.—OR. m.


                       SPECIES III.

               EMPHLYSIS VACCINIA



 vesicles few or a single one; confined to the part affected ;
   circular,  semitransparent,  pearl-coloured ; DEPRESSED in
   the middle : 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 disorderea.  It had been found to secure persons from the
 smallpox ; 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 th. cow  pox, was treated  with  ridicule.  A  formal  trial  was
 made, however, and it was found that no smail-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 theattempt is said to have succeeded completely.
 Similer facts and numerous  examples of them were accordingly
 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 difficulty
 in  determining the period of time within which  the vacine virus
maintains  its  prophylactic power.   Having at length,  however,
made himself master of the distinctive characters of the eenuine
 vesicle, he  ventured to publish the  discovery in   1798, and to re-
commend  inoculation with  the virus  of vaccinia as a substitute for
Wn    /   Tvu  1Snknown l0  every  one: the discoverer has
 been justly and liberally remunerated by parliament, and vaccine
• Evidence delivered before the Committee of the House of Commons. 
ICE. II.—SP. III.]
SANGUINEOUS FUNCTION.
395
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:

«  Nativa.                       Genuine cow-pox as it ordinari-
   Natural cow-pox.                ly appears on those who ac-
                                  cidentally receive it from the
                                  affected cow.
f  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.
i?  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 bluish 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  centre.   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 distention, and become troublesome sores, healing slowly,
and occasionally assuming a phagedenic appearance.  The fever in
the meanwhile abates and  ceasts 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 if 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 spurious cow-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-
cles are less uniformly circular; purulent from the first;  without 
390
HJKMA'I ICA.           [CL. HI.—OR. B5,
the bluish  tint; with little or  no central  depression.   Whethcr
this, in the animal itself, be strictly a variety of a common species,
or a distinct bpecies 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 s.ngle, confined to the puncture:
cellulose; bluish-biown 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 centre 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 dibtended  till the
tenth day: at which times it displays to perfection the peculiar fea-
tures that  distinguish it from ihe inoculated variolous pustule.   Its
shape is circular, sometimes.a  little oval;  but the margin is always
well d« fined, and never rough or jagged ; the centre dips instead of
beirs polarised, and is 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 ap :etite, and increase of pulse. These may continue
in  a greater or less degree ior one or two c'ays, but always subside
 spontaneously, without leaving any  unpleasant consequence.  Dur 
DE. H.—SP. 111.]   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 gradu-
ally 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 ihe thirteenth day  from inoculation.  At this time
the vesicle  hardens into a  thick scab of  a brown or mahogany co-
lour; 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 cow-
 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; hut 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 lo 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 immediately 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 slated that the genuine cow-pox itself has not
 proved a permanent prophylatic  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 smallpox  occurring afterward seems to have been chang-
 ed from its natural course, and rendered milder and of shorter dura- 
 398                      HJEMAT1CA.           [CL. III.—OR. HI

 don; 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.  Perthollet, 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 Nation*! 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 m 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 vaccinat-
 ed 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. 
OE. II.—SP. HI.]     SANGUINEOUS FUNCTION.
S99
tiou, very large, and a few of them just beginning to turn brown on
the apex, so thai it will not be necessary to follow up the description
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 same effect
seems to have followed upon  inoculation with the sanious discharge
from the heels of horses afflicted with the disease called grease. And
Dr. Jt.nner, 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
previously feeding, and  her udder coming in contact with the dis-
 charge which  had dripped on the grass and lodged there :  and he
 endeavoured  to show the identity of the  fluids by the  identity of
 their effects in respect of the small pox.—So far as can be judged
 from the few cases before us, performed indeed in different coun-
 tries, but still few in respect to the number necessary to establish  a
 positive proof, grease-pox seems  to have succeded 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 ne-
 cessary to search for them : none can surpass, and none be expect-
 ed 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, ex-
 cited from the first so deep and extensive a  disgust, that cow-pox
 inoculation had nearly fallen a sacrifice from the supposd 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, the disease is by no means the origin of the
 natural cow-pox, and has no connexion with it. 
400
HJEMATICA:
[CL. HI.—OR. Hff
                        SPECIES  IV.

               EMPHLYSIS  VARICELLA.

                        Wattv^oj:.

 VESICLES SCATTERED OVER THE RODY; GLABROUS ; TRANSPARENT ; PEA-
   SIZED J IN SUCCESSIVE CROPS;  PELLICLE THIN ;  ABOUT THE THIRD
   DAY FROM THEIR APPEARANCE BURSTING AT THE TIP, AND CONCRET-
   ING 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 :

 et Lentiformis.          Lentile-shaped,  or  irregularly  circular,
   Chicken-pox.           flattened at the top;  fluid at first pel-
                          lucid, then whitish;  afterwards straw-
                          coloured.
 p Coniformis.           Vesicles  acuminated;   fluid   pellucid
   Swine-pox.             throughout.
 y Globularis.           Vesicles globular and   larger;  fluid at
   Hives.                 first  whey-coloured,   afterwards   yel-
                          lowish.
 ? Corymbosa.           Vesicles  clustering  upon  a  common,
   Clustering water-pox.    but broader base; redder at the  first,
                          and later in appearance ; febrile symp-
                          toms 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 who 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, 
GE. U.—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 pus till the seventh day, and often much later.  Like tbe
 small-pox it does not attack the same person a second time, ex-
 cepting in a few anomalous constitutions, that establish rather than
 oppose the general rule.  " I wetted a thread," says Dr. Heberden,
 " 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 Ihe fever; the pain likewise of the limbs and
back still  continues, to which are joined pains of 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."f
* Medical Transactions, Vol. I. Art. XVII.
f Med. Trans, ut supra.
Vol. II—3 E 
IQ0,                      HJF.MATICA.        ' [CL  III.—OR. Ill


                       SPECIES V.

             BMPHLYSIS PEMPHIGUS

              Ossicular, or Jfrlatfteri) jpefccr.

VESIOLES SCATTERED OVER THE BODY J TRANSPARENT J FILBERT SIZED ;
  WITH A RED INFLAMED EDGE, BUT  WITHOUT SURROUNDING  BLUSH
  OR  TUMEFACTION;  ON BREAKING, DISPOSED TO ULCERATE;  FLUID
  PELLUCID, OR SLIGHTLY COLOURED; FEVER A TYPHUS.

The term pemphigus is  derived from the Greek Tf^j|, " flatus,
bulla," 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 ery-
sipelas vesiculare :* Dr. Cullen seems to have been of the latter at
the time of drawing up his definition, and still later, at that of draw-
ing 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 sub-
joined note, which intimates that his opinion was altered in  conse-
quence of his having seen a patient shown  him by Dr. Home, and
who was labouring 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 o£ 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:—

 » 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


                   • Art. Soc. Med. Hafn. torn, h 
GE. II.—SP. V.]      SANGUINEOUS FUNCTION.
403
                                 mouth and intestinal canal; fluid,
                                 on bursting, yellowish ;  some of
                                 the vesicles  livid, with a  livid
                                 base.
 p Glandularis.                 Preceded by tumefaction of theheck
   Glandular vesicular fever.      and throat; vesicles chiefly seat-
                                 ed on the fauces and conglobate
                                 glands; occasionally producing
                                 abscesses;  highly contagious.
./ Infantum.                   Vesicles irregularly oblong,  with
   Infantine vesicular fever.       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
 major of Sauvages, a very marked case of which was given in a com-
 munication of Dr. David Stewart to Dr. Duncan of Edinburgli,*  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 unventilaled apartment.  He was receiv-
 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 sur-
 face was interspersed with vesicles of the size of an ordinary wal-
 nut;  especially the breast and arms.  In the interstices the appear-
 ance of the skin was natural; and the distance from one vesicle to
 another 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 directipn;  nor lower than this region in the.
 severer case described by 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 heal-
 ed till the twenty-first day.f  In a case apparently of the same kind,
• Edinb. Med. Comment. Vol. VI. p. 79.
f Epbenr. Aefc Nat Cur. Dec* I. Ann. viii; Obs. 56. 
404                      1IJEMATICA.           [CL. HI.—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 bullae healed in succession without any trouble.*  None of
these appear to have been contagious.
  I 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.f  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
fauces, 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 thorax, 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 the  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 pc
• Vol. 1.1787.
t Apt. Helvet. torn, II. p. 26CK 
GE. H.—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 sudorifics;
and at the same time  supporting the strength with camphor  and
other cardiacs.  He commenced his process, however, by venesec-
tion, which was sometimes repeated,  and, where  there was danger
of an abscess in the  lungs, unquestionably with great judgment.
  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 sjeep requires it. 
400                     HJBMAT4CA.           i^L- HI—OR. IIT.


                        SPECIES  VI.


             EMPHLYSIS ERYSIPELAS.

                   St. &ntnouH's JPfre.

 vesication diffuse ; irregularly circumscribed ; APPEARING on 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.  Plegmon is local inflammation tending to sup-
 puration ; 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: phleg-
mon and erythema have no such tendency.
   The varieties of this species are very differently given by differ-
ent writers; by many of whom they are multiplied most unnecessa-
 rily.  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 derived.''*
And he  has added a case, in which the mother of a young girl se-
verely affected with this disease  appears to have received it in con'
sequence 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.t  One of  his examples ex-
tends  to four individuals, who received the disease in succession af»
ier direct contact or near  approximation with each other; and anp-
ther gives us a like line of not less  than six in descent, all of whom,
  ' On Cutaneous diseases, p. 514.
  t Trausact. of Soc. for the Improvement of Med. and Chir. Knowledge,
Vol IT. j). 213. 
I.E. 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 lageliire, which 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, as well 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 :

  *. 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 vcrboi 
408
HEMATIC A.
[CL. HI.—OK. 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 paim
 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 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 arc
 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 loosing 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 eighth or ninth day, but
 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 plegmon 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 Med. torn. LI.  p. 315.—Eph. Nat. Cur. Dec. II. Ann. IV. p. 52; 
GE. II—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, according to De Roma,  the malady  has
proved fatal.t  The distuibance  of the constitution  is less violent
when the erythema appears in the extremities.  Trie limbs most
affected are the legs, in which probably from their depending situa-
tion, the vesications fill rapidly and break within twenty-four hours
fiom their first appearance.  Salmuth relates a case in which the in-
tumescence extended ever the entire frame :t 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 ars 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 instances,
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 edematodes, and e. gangrenosum of Dr. Willan,
appears to be misnamed, and consequently misplaced.  They are
more accurately erythemata, and  have already been described under
the species erythema edematosum, 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 eyery 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, § 289.
              f Consult. Med. Chirug.
               t Cent. I. Obs. 32.
   Vol. II.—3 F 
 41o                     ILEMATICA.             [CL. III.—OH. Ill,

 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 animal 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 efflorescence.  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 irrritation.
• Stoll, Rat. Med. V. p. 436.
f Alberti, Jurisprud. Med. HI. 796.
t Pelargus, Med. Jahrgange, V. 185.
§ Medical Communications, II. 4.
8 Id. II. 3. 
ge. in.]
SANGUINEOUS FUNCTION.
4U
                      GENUS III.


                       EMPYESIS.

                  pustulous Kjrauthnn.

ERUPTION OF PHLEGMONOUS PIMPLES;  GRADUALLY FILLING WITH A
   PURULENT 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 t/vrvoa, or
tftxvtu," suppuro." The Greek writers also use, and perhaps more
generally, ecpyesis, from ex.7rvou, 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 been yet  discovered, and that is,

        EMPYESIS VARIOLA.                 SMALL-POX.
                        SPECIES I.

                EMPYESIS  VARIOLA.

                        Smaller.

 PUSTULES APPEARING FROM THE THIRD TO THE FIFTH DAY; SUPPU-
   RATING FROM THE EIGHTH TO THE TENTH : FEVER A CAUMA :  CON-
   TAGIOUS.

 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 Europe; and
from the  accounts of the Jesuits, to which we shall have  to refer

        • Hahn, variolorum Antiquitatcs e Graecis eruts.  1734. 
Ai<-2
HJEMATICA.
[CL. HI.—OR. IH.
more particularly presently, it is  highly probable that the art of
inoculation was practised throughout the  Chinese empire, before
the natural contagion had reached the European shores. About the
middle of the sixth century it is supposed to have been conveyed by
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 far as
their writings have reached  us,  make mention of the contagious
properly 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, precipue 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 disease,
little is to be added  to Rhazes' statement, and, what  is more singu-
lar, he recommends the cool treatment.   Unfortunately,  however,
the doctrine of concoction and despumaiion of the humoral patho-
logists spread afterwards so widely, and was so generally supported,
as to put to flight this correct and rational view of the subject; 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 themselves,
thus  completely reversing the law of scarlet-fever;  a remark for
which we were first indebted  to the sagacious eye  of Sydenham.
And hence in the confluent variety the eruption appears on the se-
cond 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
 ts 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. m.—SP. I.)      SANGUINEOUS FUNCTION.              413

through the disease regularly,  yet the progress of the small-sox
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 ensuing
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.  " I 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. III. p. 443.
f Treatise on Fevers, Small-pox, &c. 
414
1LEMATICA.
[CL. III.—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 ante-
 cedently.
   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
 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, I 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; amohg which  we can find
 little difficulty in placing that of Borrelli, containing the history of a
 woman  who recovered from seven distinct attacks of smallpox, 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 ihe 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 like 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. XVII. 
GE. III.—SF. 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 re-
covers 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 intermit-
tents, 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.  Pro-
vided 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 it is 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 per-
petually  witnessing cases, or rather were, when variolous inocula-
tion 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 circum-
stances, and even charged with the nature of the virus, is obvious
from  the frequent  communication of the  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 :\ and others have occur-
red since, and are  noticed in several journals of later date.
  In these cases there is no assimilation or multiplication of morbid
• De Variolis, Cap. IV.
f Sur la Grossesse, et d'Accouchement des Fernmes. Obs. 600. et 576. 
416
HJEMATICA.
[CL. III.—OR. III.
 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 sur-
 prised at  the mode by which family taints, as gout,  scrofula, 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 preg-
 nant 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 re-
 ceived 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
 inflammation on their own surfaces, and driving it altogether exter-
 nally, 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 ra-
 mifications, and the entrance of the meatus auditorius. As a gene-
 ral rule, pustules are never found in the rectum, but if there be
 any prolapse, 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 gene-
 rated in the living body, does not appear to be very volatile in any
instance, and soon dissolves in a pure atmosphere.  The contagion
 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. II. Art. XIX. 
GE. III.—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 lo 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 on  this disease have subdivided it into an endless
 multiplicity of forms: but the four following varieties are sufficient
 to include the whole :

        » Discreta.                 Distinct small-pox.
        C Confluens.                Confluent small-pox.
        y Degener.                 Crystallized-pox.
                                   Horn-pox.
        2* Inserta.                  Inoculated small-pox.
   The pathognomic characters of the first variety or distinct small-
 pox are  the following : Pustules pea-sized; distint, distended, cir-
 cular ; the intervening spaces red; the fever ceasing when the erup-
 tion 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 full crop of them  over every
 part of the body, though  the face is, in almost all 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 pimbles 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, measur-
 ing the diameter of a pea, dry away by degrees and scale off, and
 wholly  disappear on  the fourteenth  or fifteenth day, with the ex-
 ception 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, accordingly 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 j but where they are very numerous, though still dis-

           • Les A vantages  de l'Inoculation, &c. Faris, 1782.
  Vol. II.—3 G 
418
IIJEMATICA.
[CL. HI.—OR. IIT.
 tinct. the soreness, swelling and febrile heat  are very distressing:
 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 symptoms.  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 of than
 the occasion justifies.
   The grand principle in  the treatment of small-pox, as of all the
 other exanthems that have passed before us,  is to moderate, and
 hecp under the fever; and, however the plans that have been  most
 oelebrated for their success may have  varied  in particular points,
  „ey have uniformly made this principle their pole-star; and  have
  ■msisled in  different modifications of fresh air, cold water, acid li-
 quors and purgative medicines: heat, cordials, and other stimulants
 having been abundantly proved  to be the  most effectual means of
 exasperating the disease, and endangering  life.
   Dr. Mead seems to have been almost indifferent as to ihe 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 : " Indicum,"  says he, " certe satis
 manifestum, quamcunque materise diminutionem, fomitem igni sub-
 drahendo, 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 variolus 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 ino-
 culation,  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 correcter 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 ptyalism ; 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
 thU 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 Iris bed, and urged 
GE. III.—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 inocu-
 lators have been bold enough to prophecy the number of pustules
 a patient would produce under a given quantity of the acid.  Whe-
 ther  any one of the acids has an intrinsic power beyond the rest haa
 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 suppurates regularly.
 The fever is violent and exhibits a synochous or typhous type; and
 instead 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  delirius.   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.   Pecu-
 liar to the confluent small-pox is salivation in adults, and a  loose-
 ness 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 plenti-
 fully  discharged; but, towards the eleventh day, which  is the pe-
 riod of the greatest danger, it becomes  viscid and is discharged
 with great difficulty; the looseness in children, however, continues
 beyond thi* 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 secon-
dary fever, as it is called, which takes place at the age of matura-
tiotr, the cuticle suddenly becomes flattened, the features sink, the 
420
IIJCMATICA.
[CL. HI.—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 pursued, 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 its susceptibility of the conta-
gion, and irritability beneath its action: and next, that in confluent
small-pox the process of maturation does not take place kindly or
perfectly, and that the fever, often a synochus, has always a tenden-
cy 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  matura-
tion, to  support the tone of the system instead of reducing it.  Cam-
phor 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
produces 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. III.-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 scrofula, consumption, and gout.
   The horn or orystalline-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 clay  : 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 simlpest 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 curly period, and appears to have
 bucn also occasionally resorted to in the Highlands of Scotland, from
 an antiquity nearly as remote; of which abundant proofs are to be
 iound in  various ailicles in  the  Philosophical Transactions.!  All
 such  practice, however, and  even the knowledge  of it, seems to
* I.ettres Edifiantes et Curieuses, &c. pn«sim.
+ See Vol. XXXI, years 1722-3, and t specially Dr. N iiliams's . couat 
422
ILtlMATlCA.
[CL. III.—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, all of 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  disease with cordials
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, had been inoculated
with general  good success; whereas, at Blanford, 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 Blanford 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. II. Art. XIX. Compare M. Gatti's No«\ elles Reflexions
si^r la Fract'rque de l'lnoculation.  Faris 1770. 
fSE. HI.—SF. 1.J
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 of 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
afcting 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 needlejoriginally 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
larger circle of inflammation, and on this account also it cannot so ful-
ly be relied on.  The puncture does not so completely disappear as in 
424
H.XMA HCA.
[CL. III.—OR. HI.
 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 spreads i.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 ihe 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

                 £arfcuncttlar=3S):authein.

eruption of tumours imperfectly suppurating with indurated
  edges, and, for the most part, a sordid, and sanious core.

The present genus, denominated anthraoia, from «vfy«g, « a burn-
ing coal," by its definition embraces two diseases  of very different
specific characters, though closely according in their generic marks'.
These are,

           1. ANTHRACIA PESTIS.             PLAGUE.
          2. ———. RUBULA.           YAWS.

  There have been, however, and still continue to be, great disputes
• Med. Trans. Vol. II. p. 282. 
GE. IV.]
SANGUINEOUS FUNCTION.
425
among the nosologists, as to the proper station of both these spe-
cies;  many contending that plague ought not to be regarded as an
exanthem, and most writers having hitherto contemplated yaws as
an impetigo, or some other dysthetic affection, Dr. Cullen has ex-
pressed a  doubt whether the first should not be removed from the
order of exanthems into that of fevers;  Vogel  has actually  intro-
duced it  into this last order; Willan has rejected it from the ex-
anthems.  Parr arranges it as an exanthem, in his article  Nosology)
having previously, 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 present 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 occur-
ring oftener than once in a man's life, we have the concurrent tes-
timony of all the writers, who have been eye-witnesses of  its effects,
that it renders every one less susceptible for a certain period after-
wards, 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
distinguished by the name of cachexies; Sauvages and Sagar arrange
it in the order tubera of this class;  Cullen in that of impetignms.
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 {cacochymie 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
appetite returning.  So  that,  like small-pox, it appears to have a
regular 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. II.—3 H 
426
11 ASIATIC A.
[CL. III.—OR. 111.
 as a pustulous exanthem, and afterwards as a mere  cuticular intu-
 mescence, returned, at last, with a decided mind to his first opinion,
 and again asserts that " the detail of symptoms shows that the dis-
 ease is truly exanthematous."
  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
 develop 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 th» 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.

                           league.

TUMOURS BUBONOUS, CARBUNCULAR OR BOTH ; APPEARING AT AN UN-
   CERTAIN TIME OF THE DISEASE : FEVER A MALIGNANT TYPHUS, WITH
   EXTREME 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
attended to or even  known.   The earliest visitation  of  the plague
that occurs in English history was in the year  430; the last time
it appeared 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 pre-
vailed since 1645.
  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 discrepancy, will be found in their explanation to  reconcile the
seeming discordancies of established authorities.

                           The disease extending to about the
                             fourteenth day; and relieved by the
                            appearance of the eruption.
« Fructifera.
  Common plague. 
GE. IV—SP. I.]     SANGUINEOUS FUNCTION.
427
                           The eruption imperfect or suppressed;
                              transferred to some internal  organ;
                              or superseded externally by stigmata
                              and  vibices.
                           The body  covered over with  trails of
                              vesicular erythema, producing deep,
                              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, whe-
 ther alone or in conjunction with the rest.   All of them appear to
 have been present and intermixed in the Aleppo plague of 1660-1-2,
 so clearly and strikingly described by Dr. Patrick Russell, physician
 at the time to the British Factory  established a' that city:  for he
 speaks of the pestilential eruptions  appearing under the form of 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 occurrence 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
 described 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 in 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,f
 and indeed all the  writers; while, in allusion to ihe 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 ;£—"  ignis noster isto sacro longb 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 (rx xifotx,)
• Account of the Empire of Morocco, &c 4to. 1809.
f City Remembrancer, passim.
* Febris Pestilens, et Pestis Opp. Sec. II. Class II.-
A Infructifera.
  Uneruptive plague.


y Erythematica.
  Erythematous plague. 
428
HJEMAT1CA.           [CL. IH.-OR. III.
while Ihe two last varieties were perpetually intermixed; the chief
eruption, however, being that of the 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,"—<P*vktxivxk
fi.txe.tis **< ttottvir.—but that the interior parts were so burning  that
the sick  could not  endure the lightest covering or  clothes,  and
eagerly threw themselves into cold water.  And  he adds, that the
disease, in its ulcerative progress, commencing in the head  or the
upper 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 sacek quom diditur ignis.j

   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
atrocissimomorbo pestilent! summam affinitatem habet;" and which
was in reality this disease in the  form before us.   " 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 ac-
cidental 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 88ih 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,f
* Hist  Lib. II. 50.
 f De Rer. Nat. VI. 1164.
 t Medical Sketches of the Expedition, &c. 
GE. IV.—SP. 1.]      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
epidentic synochus of great violence and danger, often accompa-
nied with symptoms of rheumatism or pleurisy, and which seems to
had 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 peison 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. Mertenshas well described this
progress in the plague of Moscow in  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 perceived 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. II  Cap. I.
  f Hist Lib. II. 49.
  t Observationes Medicae de Febribus putridis, de Peste, nonnullisque aliis
morbis.  Vindebon.  1778. 
430
HJEMATICA.          [CL. 1II.-OR. III.
 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 tumours made their appear-
 ance." In such cases, an erupiion of petecchiae, maculae 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 thgsc
 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 litile progress during the  earlier  part
 of the year, but became fearfully fatal with the advance of summer,
 and gradually  died  away  with the frosL   The  mortality was  tre-
 mendous.   Seventy thousand inhabitants were  cut off in a  few
 months, twenty-two tbcusand 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 ot  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, w.dch 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.  I did not take this
 precaution, but occasionally rode out to take exercise on horseback.
My daily observation 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." 
GE.IV.—SP.L]      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 in-
tercourse, by showing  how very rarely  the medical attendants suf-
fered.
  Yet fresh  persons  are far less safe  than the stated inhabitants of
an infected 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 hav-
ing 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 not having time
to bury the dead, the bodies were deposited  or thrown together into
large holes, which when nearly full, were cov%r«l 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 depressing passions
of fear and grief had also a strong predisposing effect: a few suffer-
ed  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  lo fifteen hundred: Te-
rodant, 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
observed, 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 per-
fect suppuration.   In many instances they neither inflame nor be 
432
HiEMATICA.
[CL. HI.—OR. Ill
come painful; and in others  they suddenly disappear after having
reached 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 innume-
rable  examples, of which it may be sufficient to quote that of M.
Mathias Degio, one of  the surgeons attached to the same establish-
ment.  " Perceiving,"says Dr. Guthrie, " the gentlemen of his pro-
fession condemned, in a manner, to death if punctual in their duty,
he had the resolution to inoculate himself for the plague in a full
confidence of its efficacy; and ever afterwards found himself invul-
nerable, while his companions around him were falling  victims to
its lury."*
  Of  the efficacy of inoculation from the virus of a bubo 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 if 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  Rosetta in 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 EI-
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 stale till the evening of the
9th, when he expired.!
  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.
VIII. p. 348.
  t Med. Trans. Vol. VI. Art. VIII. 
HE. IV.—SP. I.J      SANGUINEOUS FUNCTION.
433
 moji 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 pes-
 tilential 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 clothes, 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 test 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 with-
 out his knowledge by  John Lee, a  private,  and servant to  the
 lieutenant, who prevailed on the sentinel 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 Health
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,
And hence it is most probable that the few  exceptions to the gene*
  Vol. II.—3 I 
434
HiEMATICA.
[CL. HI.—OR. IB.
ral fact proceeded from a disobedience of orders which the Brard
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, how-
ever, retaining the  characteristic test of glandular affection: and
on the 24th of June, the Turkish government announces  to  the
public its supposed  cessation by a discharge of cannon.
  Sir John, however, with  great judgment, entertains doubts of its
entire cessation even then or at any time ; and brings  a  proof or
two of its existence during  the period of official emancipation.  In
few words, he conceives the plague 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 established at the camp was
broken  up, I discovered that the Arab servants, who had been
employed in it, had  secreted a great part of ihe 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 Mogadore: 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 bubo, 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 fo
 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's 
GE. IV.—SP. I]      SANGUINEOUS FUNCTION.              435

heart,  and will not be  read  without feeling by the most torpid.
kt As I approached the beach to examine them (the sick and sus-
pected of the Major transport,) the first object that presented itselt
was a  young  woman supported  in a  chair (Francisca Kenms,)
moaning under oppressive disease.  She stared wildly about, quite
insensible to  every  object around her, and  there was a muady
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 suf-
ferings."*                                                 .
   Upon an  average, from  a table of the general  return  ot 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
 aees 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 character; and 1
 have dwelt upon it  the more largely,  because, from  the  time ot
 Dr Cullen to the present day, its discrepancies have been chiefly
  •mended 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,t or that ot atmo-

    * Loc citat  p. 148.
    tLanee Rudimenta doctrine de peste.-Magirus, Von der Pest.-Maclean,
 Results of an Investigation respecting epidemic and pestilential diseases, in-
 eluding researches in the  Levant concerning the Plague. 
436
HAEMATIC A.
[CL. 111.—OR. Ill;
spheric influence,* some have been equally inclined to sweep the
whole away at once, and  to  reduce  it to a mere modification of
typhus or some other fever of great malignity.!
  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'drop,
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: j
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.
  Next, 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
  • 6ir Brook Faulkener.—Tully, Hist, of Plague in the Islands of Malta,
Gozo, Corfu, &c. 8vo. 1821.
 f Dr. W. Heberden, Observations on the increase and decrease of different
diseases, particularly the plague, 8vo. 1801.—Dr. Hancock, Researches into
the laws and phenomena of pestilence, 8tc. 8vo. 1821.
  * Edin. Med. Com. Vol. IU. p. 352. 
GE. IV.—SP. I.]       SANGUINEOUS FUNCTION              437

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 exten-
sive 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  symptoms 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 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  rdj^ect 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 to 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 problem to the present hour; though it is probable that the law
 which in this respect governs most of the other exanthems, as mea-
 sles, 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. II. p. 52. 
4S8
ILEMATICA.
[CL. III.—OR. Ill
   observed at  some length that whenever originating from the hu-
   man body itself, the 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 Mait-
   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.
   Tully's : " It is communicated,"  says he,  "only by contact or close
   association with  the person  or thing  infected/'t   And in conse-
   quence they admit that the air, even in its  purest state, may become
   a vehicle of communication, though to a very short  distAce, and
   probably 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
   ihe 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.
  f Mi-mtes of Evidence before the Select Committee of the House of Com-
mons. 
RE. IV.—SP. 1.]      SANGUINEOUS FUNCTION.               43«|

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 only 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
distinguished 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  a  shadow of a doubt; for, though the
 miasm is probably communicable within the sphere of its activity,
 by the mouth or nostrils, direct contact 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 sovereignest thing on earth" in
 the last pestilent ravage at Malta; and Mr. Tully has informed me
 that there was no instance of an  attendant en the infected having

 " Treatise on the Plague, by Sir Arthur Brooke Faulkner, M. D, 8vo. 1820 
440
1UEMATICA.
[CL. 111.—OR. Ill
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 Malta 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 I 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, by 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 Egypt 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 similar remark is made by Mr. Jackson respect-
ing the  crolies or labourers in oil-warehouses during  the Barbary
plague just referred to.   In that of London in 1665, it is specially
observed by Baynard, and most of the writers, that the trades chiefly
exempted were those 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 ex-
posed lo 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 fo  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 jail-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 Minutes, &c. As also Sir A. B. Faulkner's Treatise on the Pl*gue,
&c. Appendix, p. 16, 8vo. 1820.
  f Ttavels, fcc. Chap. XVII. 
OE. 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 expbsure 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
atmospheric 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 of 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,
where persons  had died, before they were cold, or cleansed from
the stench of the diseased :for the nature ofche disorder was chang-
ed*  " Even the physicians themselves," says another eye-witness
of the same  pestilence, " were surprised:  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.
                    f Journal by H. F. p. 250.
Vol. II.—3 K 
442
HJEMATICA.          tCL. III.—OR. III.
   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. Russel confirms
this remark as follows :—" It is agreed on all  hands that about the
24'.h of June,  at Cairo, there is a remarkable sudden  alteration in
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
on 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, I
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. IH. Ch. V. 
GE. 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 at 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 ODlSet, 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 utility
 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 cangeslion 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.f If the
 nausea  and  bitter taste  in the mouth be not removed by a first
 emetic,  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 un-
 able to support.
  After evacuating  the stomach, and hereby exciting a determina-
 tion towards the skin, the cutaneous action is to be  maintained by
 active 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 vascu-
  * Loco citato.
  f Substance of notes taken at the Russian army during the prevalence of
: ho Plague.  See Edin. Med. Com. Vol. VIII. p. 352. 
444
HEMATIC A.
[CL. III.—OR. in.
lar 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
effects, though he regarded the practice as hazardous. With respect
to sudorifics, the concurrent voice of all physicians in all countries,
isin their favour. Diaphoresis is, indeed, the evacuation that relieves,
most certainly and most effectually; and it should be maintained 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 severe.
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  "a gen-
tleman 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. 2"1, 232. 
GE. IV.—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 j
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.

                           Setoff.

iLMOURS NUMEROUS AND SUCCESSIVE ; GRADUALLY INCREASING FROM
  SPECKS TO THE SIZE OF A RASPBERRY:  ONE AT LENGTH GROWING
  LARGER THAN THE REST;  CORE A FUNGOUS EXCRESCENCE; FEVER
  SLIGHT:  OCCURRING ONLY ONCE DURING LIFE :  CONTAGIOUS.

The term rubula, by which this disease is distinguished in the pre-
sent work, is derived from the Latin rubus, " a blackberry or rasp-
berry," in French framboise, whence the common but barbarous
name of frambesia, 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 accordauce with  the ordinary
law of diminutives, which seems to prevail through the general no-
menclature of exanthematous diseases, as rubeola, variola, varicella
•  Tr«»f;se on the Ptagne, p. 2'"5 
446
H-£MATHJA
[CL. HI.—OR. 111.
   Perhaps mprula, from moms, 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 raspberries.   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 yaio, and on the
   latterpian or epian,  both importing raspberry; and as the earliest
   writers have, upon this authority, denominated it framboise ovfram-
   bxsia, I have not felt myself at liberty to deviate from the original
   idea.
     The disease, as it  occurs in Africa and America, exhibits  some
   diversity, and lays a foundation for two varieties as follow:

   * Guinensis.              >     Attacking infants and young per-
     African Yaws.                  sons  chiefly ; and subsiding as
                                    soon  as the eruption appears.
   /3 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 sibbensor 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
   symptoms, 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 that under 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.  Flence 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 raspberry or mul-
   berry. The smaller papulae become real pustules, and discharge ?.'. 
GE. IV—ST. 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 veryim-
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 grcins,
parotid glands, axillae,  and about  the arms and pudenda: though
they often disfigure the neck and  face.  The  colouring matter of
the hair,  wherever they are seated, is obstructed  in its secretion,
and, as in old age, the hairs themselves, from a brown or a black, be-
come a dead white.   Dr.  Thomas, who has given a very accurate
account of this variety, apparently from personal knowledge, ob-
serves that, " in  general the number and size of the pustules are
proportioned  to the degree of eruptive fever.   When the febrile
symptoms are slight, there are few  pustules; but they arc 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 sloughly fungus, and discharges a
larger portion of erosive sanies, which if not washed off as it issues
will spread widely,  and sometimes work  its way  to an  adjoining
 bone, and render it carious. When the tumours point from the soles
 of the feet, they cannot press through the thickness of the skin, and
 hence acquire form imperfectly, and produce highly elevated cal-
 luses, 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 patient from his associates, to  whom he
 will otherwise assuredly communicate it by contagion.  He should
 then take freely  of decoction of sarsaparilla or some other warm di-
 luent, for the purpose of attenuating the specific virus in the blood,
 and quickening its passage towards the surface.  And it is  highly
 probable that the warm aperient bolus, composed chiefly of a scru-
 ple of sublimed sulphur and five grains of calomel as recommended
 by the anonymous writer of a very excellent treatise upon the sub-
• PracL of Phys. p. 643. ed. 1819. 
44S
HEMATIC A.
[CL. 111.—OR. HI.
ject in the Edinburgh Medical Essays,* may be found serviceable,
continued every night.   The master-yaw must be attacked with es-
charotics, for it is to be destroyed in no other way.  The callous tu-
mours on the soles of the feet should be softened  by warm water,
or cataplasms of some  gentle stimulant; and, when on the point of
breaking, are best attacked with a slight application  of the actual
cautery, which proves  the most advisable  escharotic.  The  diet
should be nutritious and liberal, so as to support the strength during
the progress of the disease.   And under this mode of treatment it
is rarely that a patient fails to  do well.
  Mercury was at one time given in great abundance from the com-
mencement of the complaint,  under  an idea  that it would prove as
beneficial as in  the case of lues.   But it is now sufficiently known
to be productive of  great  mischief, and particularly when carried,
as it used to bA 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 soraid 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.f
  The  second,  or American variety, is a far more terrible  com-
plaint; or rather is the same complaint in an exasperated and chro-
nic form; and hence, though incomparably  slower  in  its progress
than the plague, is accompanied with a carbuncular eruption quite as
mischievous and disgusting, and 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 into the  West Indies along with  the
slaves from  the African coast; and is here called, as already  ob-
served,  pian or epian, precisely synonymous with the African term
yaw: the master-fungus being named mama-pian,or mother-yaw, as
supposed to be the source  or supply of  the rest.  The fungus 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. II. Art. LXXVI.
t Edin. Med. Com. Vol.H. p. 90. 
 6E. IV—SP.H.]     SANGUINEOUS FUNCTION.              449

 and  blackish-green colour of the fruit or berry of the pine-nut, or
 terminthus of the Greeks."*  And it has hence been conjectured,
 but without sufficient  foundation, that the disease of yaws is refer-
 red to by Galen and Dioscorides under this name.
   The erosive secretion from the carbuncles of this variety, gene-
 rally, but especially from the mother-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."t  Dr Pinckard adds, that " unhappily this most odious
 distemper  has not  hitherto been found within the power of  medi-
 cine : that it often exists for years, and even 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:
probably  from using  a better diet and  being  more attentive  to
cleanliness.
       • CL. HI. Ord. II. Vol II. p. 194.
       f Notes on the West Indies, Vol. U. Letter XXII.
Vol. II.—$ L 
      CLASS  III.

HiEMATICA.
                       ORDER IV.

                    DYSTHETICA.

                        CTachefrfes.

MORBID  STATE OF THE BLOOD OR BLOOD-VESSELS;  ALONE OR. CON-
  NECTED 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 impeti-
go, or, as the Greeks expressed it, Xvik, lues, or lyes.   None of
these, however, exactly answer; and that on tw > accounts; first,be-
cause the order is limited to those depravities which seem to origi-
nate or manifest themselves chiefly in vessels or fluids of the san-
guineous function; and, secondly, because no very definite sens ehas
hitherto been assigned to either of these terms; and they have, in
consequence, been used in very different meanings by different
writers, from the time of Celsus to our own day.
  Upon this subject the author has dealt at large in his volume of
Nosology, and it is not necessary to add to the remarks there offer-
ed. The word dysthetica has hence been adopted for the purpose
ofavoiding confusion, and is justified by the eusthesia and * us the-
tica (EY20E2IA and ETS0ETIKA) of Hippocrates and Galen, im-
porting a " well-conditioned habit of body," as their opposite dys-
thetica, from the same root,  imports  an " ill-conditioned habit,"
but a habit, as just observed, originating in, or dependent upon, the
organized parts or fluids of the sanguineous function.  Thus ex-
plained, it will be found to embrace the following genera:

           1.  plethora.        plethora.
           2.  h&morrhagia.     hemorrhage.
           3.  marasmus.        emaciation. '
           4.  struma.           scrofula.  king's evil.
           5. carcinus.         cancer.
           6.  lues.              venereal disease. 
C.E. I ]             SANGUINEOUS FUNCTION.               451
 T. ELEPHANTIASIS.    ELEPHANT-SKIN.
 8. BUCNEMIA.        TUMID-LEG.
 9. CATACAUSIS.       SPONTANEOUS IGNESCENCE.

10. PORPHYRA.        SCURVY
11. EXANGIA.          VASCULAR DIVARICATION.

12. GANGRiENA.        GANGRENE.
13. ULCUS.            ULCER.
                       GENUS I.

                     PLETHORA.

                          plethora.

COMPLEXION FLORID; VEINS DISTENDED; UNDUE SENSE OF HEAT AND
  FULNESS ; OPPRESSION OF THE HEAD, CHEST, OR OTHER INTERNAL
  ORGANS.
Plethora is seldom ranked as a disease, and hence seldom treated
of in a course of medical instruction.  From what cause this omis-
sion proceeds I know  not,  nor is it worth while to inquire.  That it
is an important omission will be obvious to every student before he
has been six months in practice; for there will probably be few af-
fections on which he will be sooner  or more frequently consulted.
Yet the subject has not always been neglected by nosologists, for
plethora, as a genus, occurs in the  classifications both  of Linneus
and Sagar.
  In a state of health, the  quantity of blood produced from the sub-
stances that constitute our common diet bears an exact proportion
to the quantity demanded by  the  vascular system in its ordinary
diameter, and the various secretions which are perpetually taking
place in every part of the body. But the quantity of blood produced
within a given  period of time may  vary ;  and the diameter of the
blood vessels, or  the  call  of the different secernent organs  may
vary; yet, so long as a due balance is maintained, and the  propor-
tions'of new-formed blood is answerable to the demand, the general
health continues perfect or is little interfered with.  Thus, a man ex-
hausted and worn down by shipwreck, or by  having lost his way in
a desert, or who is just recovering 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 ordi-
nary wear of life; but the whole system demands this double exer-
tion ;  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 
452
HJBMATICA.           [CL. HI.—OR. iy.
 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 ac-
 tivity  of the secernents; and  hence the difficulty to which the ani-
 mal 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 capa-
 city  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
 balance between the substance contained and the substance contain-
 ing, and that the measure of the former must be too large for the
 measure 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 dis-
 tinguished by different names ; that proceeding from an actual sur-
 plus of blood being denominated a plethora ad molem, or a plethora
 in respect to its general mass,  or absolute  quantity; and that pro-
 ceeding from a diminished  capacity of the  vessels being denomi-
 nated 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 vigor-
 ous  action or entony of the organs of sanguification, we often see
 proof of the same entony or highly vigorous action through the whole
 range of the vascular system, and indeed of  every other part of the
 machine;  the pulse  is full, strong, and rebounding; the muscular
 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  Plethora.
  But we often meet with an inordinate formation of blood in a con-
 stitution  where the  vascular action is  peculiarly weak instead of
 being peculiai ly 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 irri-
 tability or deficiency of strength in the organs of sanguification.
  Yet, though the cause is different, the result is the  same ; the ves-
 sels, notwithstanding their facility of dilatation, at length become
 distended, and a plethora is produced which has been denominated 
GE. I.—SP. 1.]     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 EIMTONICA.         SANGUINE PLETHORA.
       2.  ------—• ATONIC A.          SEROUS PLETHORA.
                        SPECIES  I.

               PLETHORA ENTONICA.

                   Sanguine Uletnora.

PULSE  FULL, STRONG,  REBOUNDING: MUSCULAR FIBRES FIRM AN*
                          VIGOROUS.

Sanguine plethora is more common to men, serous to women. It is
the disease of manhood, of the robust and athletic.  Plethora of this
kind must be distinguished from obesity;  in effect, they are rarely
found in conjunction, for the entony or excess of vigorous action is
common to every part of the animal frame, and hence, though it is
probable that a larger portion of animal oil is secreted than in many
other conditions of the body, yet it is carried off by the activity of
the absorbents, and there is no leisure for its  accumulation in the
cellular membrane.  And hence persons labouring under sanguine
plethora are rather muscular than fat, and their distended veins lie
superficially, and appear to peep through the skin.
  In this state of the blood-vessels, slight excitements produce con-
gestions in the larger vesseU 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 inflamma-
tory type; and a slight excess  in feasting or  conviviality  will en-
danger 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 venesec-
tion and  purgatives j and its disposition to return may commonly 
454
ILEMATICA.
[CL. Ill—OR. IV.
be prevented by the use of refrigerents, as nitre, or other neutral
salts- and an adherence to a reducent diet and liberal  exercise; at
the same time it should  be observed,  that where the plethora .de-
pends  upon a 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  II.

                PLETHORA  ATONICA.

                     herons tttrthora.

 PULSE FULL, FREqUENT, FEEBLE :  VITAL ACTIONS  LANGUID J SKIN
       SMOOTH AND SOFT; FIGURE PLUMP, BUT INEXPRESSIVE.

 The general pathology we have already treated of: and the reasons
 given under the lust species for the usual appearance of sanguine
 plethora in persons of a spare and slender make, will explain the
 plumpness of figure and glossiness of skin which so peculiarly mark
 the species before us.   In the first, there is great and universal vi-
 gour and rapidity of action ; the  secretions are all hurried forward
 in their elaborations, and carried off as soon as produced.   In the
 second, 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 6udden attacked with flatulent spasms, or a
 troublesome looseness.  The appetite is languid and capricious; the
 heart  teased  with palpitations, the chest with dyspncea and wheez-
 ing ; the head is  heavy and  somnolent; the urine pale, small in
 qudiuiiy, and discharged frequently.
   In this species,  as in the last, we are compelled to begin with
 cupping, or the use of the lancet.  But, though the distended and
 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 us far as
possible should  undergo a total change.  The diet should be  nutri-
tious, but perfectly simple, and the meals less frequent or less abun-
dant than usual; the sedentary life should give 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 spee-
dily be thrown off, it is a mischievous doctrine in medicine. Health
being the middle term between excess and deficiency, every day is
giving us a proof that where either of these extremes has become
habitual, the system can only  be let up or let down by slow degrees,
so as to reach and rest at the  middle point with  certainty, and with-
out inconvenience.  Professor Monro has furnished us with several
very striking  examples of this fact; and particularly among those
who had acquired  a habit of drinking very  large quantities of spiri-
tuous potation.  A man of this description who had  broken both
bones of one leg, and was put, for a more speedy recovery, upon a
diet of milk  and water and water-gruel,  was hereby 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-standerand friend of the patient's
of the same irregular habit,  ventured to tell the professor that he
would certainly kill him if  he did not allow him ale and brandy ;
since, for several years antecedently, he had been accustomed to
both these as his common drink ; a little of each was in consequence,
permitted him; but the patient's  friends did not tie him down to
this little : for extending the grant of an inch to an ell, they instant-
ly gave the man a Scot's quart of ale and a gill of brandy, which was
his usual allowance for the evening, he slept well and sound; the
next morning was free from  delirium and fever; and, by a perseve-
rance in the same regimen, obtained a speedy cure without the least
accident.*
• Edin. Med. Ess. Vol. V. Part II. Art. XLVI. 
JLi---^__
 45g                     H2EMATICA.           [CL. HI.—OR. IV


                        GENUS II.

                    HiEMORRHAGIA.

                        f^emorrhage.

          FLUX OF BLOOD WITHOUT EXTERNAL VIOLENCE.

 The term haemorrhagia, or hemorrhage, is derived from the Greek,
 xifjux. " sanguis," and favvu, " rumpo."  Dr. Cullen has adopted the
 same name for an order of diseases ; but there are few parts of his
 arrangement that  are more open to animadversion, and which in
 fact, have been more animadverted upon than  the present.   The
 order of hemorrhages, or fluxes of blood, ranks in Dr. Cullen's sys-
 tem under the class pyrexiae, or febrile diseases.  Pyrexy, howe\ er,
 is only an accidental symptom in idiopathic hemorrhages of any
 kind, and has hence been admitted 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 ofprofusions, instead of by their own  pro-
per denomination.
  Blood, from whatever organ it flows, may have two causes for its
 issue.   The vessels may be ruptured by a morbid distention and
impetus ; or they  may give way from debility and relaxation, their
 tunics breaking without any peculiar force urged against them, or-
their exhalants admitting the flow of red blood, instead of the more
 attenuate serum.  To the former description of  hemorrhages Dr.
 Cullen has given the name of active ; to the latter that of passive.
 The distinction is sufficiently clear;  and under the names  already
 employed in the preceding genus of this system will lay a  founda-
 tion for the two following species :—
    1. HjEMOKRHAGIA ENTONICA.   ENTONIC HEMORRHAGE.
    2.     -..,------ ATONICA.    ATONIC HEMORRHAGE. 
 GE. II.—SP.I]       SANGUINEOUS FUNCTION.              457


                        SPECIES I.

            HjEMORRHAGIA  ENTONICA.

                   aSntomc  ^cworrnasc.

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

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

 * Narium.             Entonic bleeding at the nose.
 0 Haemoptysis.         ------ spitting of blood.
 y Haematemesis.       ------ vomiting of blood.
 ^ Haematuria.          ------ bloody urine.
 e  Uterina.             ------ uterine hemorrhage.
 £ Proctica.            ------ anal  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-
 gan than belongs to the vascular system generally.  But there are
 other and more extensive causes that operate upon some organs, and
 which consist in  an unequal distribution of the blood and its peculiar
 accumulation in  some vessels rather  than in others.  Thus,  some
 organs acquire development and perfection sooner than others, of
 which the head,  peculiarly large even in infancy, furnishes us with
 a striking example:  and, in the promotion of such development,
 the 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 lender, 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 surface
 of the nostrils, and covered only with thin and weak integuments.
 And, on this account, we see why young persons are so much more
 subject to bleedings from this organ than those  in mature life. Hae-
moptysis, or spitting of blood,  takes place more commonly a few
years later, and when the animal frame has acquired its full  growth,
and consequently the vascular system its full extent or  longitude.
Antecedently to  this, the impetus and determination of blood are
  Vol. II.—3 M 
458
lLUMATJCA.
[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 lo expect hemorrhage from the respiratory organs.
When this  term,  however, has arrived, the bias is thrown on the
other side; and the vessels of the corporeal and of  the  pulmonary
circulation  being  equally perfected, the tendency to accumulation
will be in the latter, in consequence of  their shorter extent.   This
tendency will  continue till about  the age of thirty-five; which is
exactly correspondent 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
Wintringham, 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 resist-
ance 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 biood is slower than elsewhere; and such congestion  alone
will frequently act upon the neighbouring arteries, and induce whal
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  erun- 
 GE. II.—SP. I.]      SANGUINEOUS FUNCTION.                459

 tions of the skin:* as also by the wound of a leech swallowed acci-
 dentally, t   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.|   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
 applied 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
 before 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
various 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.l   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 spontaneous
 hemorrhages; and that is, the profuseness of the discharge  which
  * Percival's Essays,  II. p. 181.
  \ Galen.  De Loc. Affect. Lib. IV. Cap. V.—Riverius, Observ. Med. Cent.
IV. Obs. 26.
  t Galen. De Loc. Affect. Lib. IV. Cap. V.—Borelli, Cent. 1. Obs. 24.
  § Schenck,  Lib. VII. Obs. 124. ex Langid.—Hist. Mort. Uratislav. p. 58.
  || Schenck,  Obs. Lib. HI. Serm. II. N. 258.
  1 Khodius,  Cent.  II. Obs. 64.—Ab. Heer. Introduct. in Archiv. Archei.
  ** Lib. II. Cap. 11.
  ffN. Act. Nat. Cur.  Vol. I.  Obs. I. 
460
HJEMATICA.
[CL. Ill—OR. IV.
sometimes takes place, and the alarming  exhaustion which fol-
lows.  Dr. Banyer, in the  Philosophical Transactions,* gives a
case of this sort, in which  the discharge was from the bladder;
Biichner, another case from the same organ, in which it amounted
to not less  than four pounds:! and other writers bring examples of
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
flow away 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.!
  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.  Vet 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 ate 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 sneering,  especially upon
the use of  sternutatories, an accidental blow upon the upper part of
the nose or forehead, or a jar of  the entire frame, as on stumbling,
should be sufficient to produce this effect, can easily be conceived;
and these, in truth, are the  common occasional causes : but it is sin-
gular that it should follow, in some  highly irritable idiosyncrasies,
upon such  very trivial excitements as have  been noticed by many
pathologists.   Thus, Bruyerin** gives an example in which the nos-
trils flowed with blood upon smelling at an apple ; Rhodius, upon
the smell of a rose ;ft and Blancard, upon the ringingof bells ;i| and

         * Vol. XLII.
         t Miscel. 1728. p.  1496.
         i Anat. Renov. Lib. 11. Cap. VI.
         § Cent. I.  Obs. 90.
         i| Act. Erudit. Lib.  1688. p 205.
         * Dec. I. Ann. HI. Obs. 243.
         *• Bruyerinus De Re cibaria.  Lib. I. Cap. 24
         ft Rhodius, Cent.  Ill Obs. 99.
          ;* Blancard, Collect. Med. Phys. Cent. VI. Obs. 74. 
GE. 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 *|x (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, ha's 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 illined with moistened powder of charcoal, which
•Rhodius, Cent. I. Obs.89.
• • 
 l0x>                     1LEMATICA.           |CL. HI.— OR. IV.

 of itself has proved an excellent styptic.  Cold applied to the back
 will succeed, but often fails ; it  is  more certain of success 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 Riedlin gives a case in
 which it was cured by sneezing ;| but this was probably a case of
 atonic hemorrhage, in which the spasmodic action might assist in
 corrugating the mouths of the bleeding vessels.
  It is rarely necessary or even proper in this variety of hemorrhage
 to employ any internal astringent or other tonic: but if this discharge
 should be excessive, and produce debility,  the same plan may be
 resorted to as will be recommended under the ensuing species.
  In haemoptysis or spitting of blood, it is not always easy to de-
 termine from what vessel  or even from what organ the  bleeding
 proceeds: for the blood may issue from the posterior cavity of  the
 nostrils, or from the fauces as well as from the lungs. If, however,
 from the first, it will tease  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, dypsncea, and
pain in the  chest.   There is usually, also, a sense of tickling about
the  fauces, which  often descends considerably  lower;   Salmuth
asserts that he has known it extend to the scrobiculus  cordis.§
 These symptoms, moreover,  indicate that the blood flows from a
branch of  the  pulmonary rather than  of the  bronchial artery.
 The blood is here of a florid hue, and the hemorrhage sudden and
often copious.   If  a branch of the bronchial artery give way,  the
flow of blood is usually much slower, and smaller in quantity :  there
are  no precursive symptoms,  the blood is rather hawked or spit up
 intermixed with saliva, and, from being longer in its ascent, is of a
darker colour.   From its lodgment, however, in the air-vesicles,
 it becomes  a cause of irritation, and a frothy cough ensues, some-
 times accompanied with a little  increase of the pulse and other
febrile symptoms, as a feeling of heat and some degree of pain in
the  breast,  which  subsides after the ejection,  and returns if  there
be a fresh issue.
* Rat. Med. Part III. p. 21.
f Panarol. Pentecost, v.  Obs. 27.
* Linn. Med. Ann. I. Obs. 24.
$ Cent. HI. Obs. 43.
• 
GE. II.—SP. I.]       SANGUINEOUS FUNCTION.              463

  If the  structure of the  lungs be sound, we have no reason to
prognosticate danger.  On the contrary, it often affords great relief
to a gorged liver, and has proved critical in obstructed menstruation.
Excreted with the sputum it is frequently serviceable, as 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 irri-
table organ.
  The general pathology  has been already laid down.   The inci-
dental causes are misformation of the chest; undue exertion of the
respiratory muscles, whether in running, wrestling, singing, or blow-
ing 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 instance the vomiting," says he, " increased the hemorrhage to
a great  and dangerous degree;  and  the possibility of such  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
  • Rat. Med. Part. II. Ch. XIX. p. 470.
  ] Keck, Abhandlung,  and Beobachtungen.   Medinisches Wochenblatt
ITS--  No. 4^. 
464
H7EMAT1CA.
[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 ur-
  gency 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 HiEMATEMEsis 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.
 Hacmatemasis, 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 ihe latter being smaller in quantity, and
 remaining a longer time in the passages,  and consequently  of a
 dark colour.  There is some ground for this opinion ; for when
 the bladder is  the  seat affected,  there  is far more local pain and
faintness, than where the  affection is in the kidneys.  Hippocrates,
indeed, has observed, that where the blood flows pure, copiously,
• Percival's Essays, Vol. II. p. 181. 
GE. II.—SP. I]       SANGUINEOUS FUNCTION.
465
 and suddenly, and  without  pain, it  proceeds from the kidneys:
 but where it  is small in quantity, and of a blackish  colour, and
 accompanied with  much heat or pain,  or both, its  source  is the
 bladder.  But this remark,  instead of opposing,  tends rather to
 corroborate the preceding ; for according to both views the seat of
 disease is distinguished by the greater or less degree of uneasiness
 that attends the discharge ; and this whether the quantity discharged
 be  larger or smaller.
  It is not often, though sometimes, an entonic disease, or an active
 hemorrhage. Its  exciting cause is frequently a stone in the bladder;
 or a violent blow on the kidneys, or on the bladder, especially 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 haemor-
 rhagia. 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 secernentsdonotat these seasons fulfil their
office, and throw  forth their proper fluid, the uterine arteries will be
inordinately gorged ; the regular stimulus will be greatly augment-
             • Lib. VII. Obs. L. 24. ex Langid.
             f Hist. Mert. Uratisbw. p. 58.
Vol. II.—3 N 
466
IliEMATICA.
[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
anastomosis; and a considerable  hemorrhage be the consequence.
  This is the ordinary period in which uterine hemorrhage  lakes
place ; though it may occur during any part of the interval between
the catamenial terms, upon any of the occasional causes that operate
upon other organs, and from the preceding varieties : as it  is also
well known to occur at times, with great violence, during  pregnancy
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 hemor-
rhage in new bom infants; of which the medical records give several
examples ; and especially the Ephemeiides of Natural Curiosities.
  In suppressed menstruation uterine  hemorrhage affords relief to
the spasms and pains that harass the loins, and  the  head-ache and
difficulty of breathing which have usually preceded the lumbar dis-
tress.  But the discharge may be immoderate, and become habitual.
And it is hence best to be upon our guard, and to use venesection as
a substitute;  and to prevent or diminish  the  spasmodic action by
gentle aperients  and the sedatives already recommended in haemop-
tysis; after which the  case will  become a disease  of suppressed
menstruation alone, and must be treated according to the method
recommended under that malady ; for a restoration of the catamenial
secretion is its natural cure.   I may here, however, observe, that
when tbe suppression of this secretion  lias 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 &ny surrounding organization, they readily give way both
in an entonic and atonic slate 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-
binthinate preparations, or even pungent aliaceous sauces.   The
irritation of 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 experi-
enced.
  This power of hemorrhage when  active, as it is called, or in an
entonic habit, is usually preceded by a sense of weight and  pain
within the rectum, and sometimes by a load in the head.   And it
has often, as already observed, proved critical and salutary, and car-
ried off congestions from the abdominal viscera.  It is, however,
peculiarly apt to become profuse, and to establish an order of re-
currence; and hence  must be overpowered  by the reducent and
sedative plan recommended in most of the preceding varieties, and
particularly in thai of haemoptysis.  The aperient employed,  how-
ever, should here  be peculiarly mild and alierant; 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 it

            H^MORRHAGIA ATONICA.

                   &tomc flemorrfiage.

accompanied with general laxity or debility; and weak, vas-
    cular action ; blood attenuate, and of a diluted red.

Though the effect in this species is the same as in the preceding,
the proximate cause, as well as the more obvious signs, are directly
opposite.   The general pathology has been given in the introducto-
ry remarks to the genus, and the more common organs from which
the hemorrhage proceeds are the same as already noticed under the
preceding species; and hence the varieties of that may be regarded
as those of the species before us.
  When the plethora is the remote cause, which it often is, it is ato-
nic plethora, or plethora of debility; but whatever has a tendency to 
468
HiEMATICA.
[CL. HI.—OR. IV.
loosen or enervate the  tone of the solidum vivum, or living fibre,
will lay a foundation for this  kind of hemorthage.  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 1 he  alimentary canal, the blood is dis-
charged without tensive pain : though there must necessarily be an
expulsive  effort; and from the inanition hereby  produced, some
degree of nausea and faintness.
  When evacuated by the urethra, there is, for the same reason,
faintness, but little  or no previous pain.  The most singular and
severest examples of hemorrhages from  the  urethra are those that
have occurred during coition; sometimes  intermixed with semen,
sometimes instead of it, and sometimes immediately after emission.
The individuals have  been generally persons of highly irrilable
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 ihe 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.   Aba  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; which, however,  they do most usually after the age of
forty or fifty.
   Atonic hemorrhage from the anus usually takes place spon-
 taneously with little or no pain ; but commonly with varices or con-
 gestions of the hemorrhoidal vessels,  and is  very apt to produce a
 habit of recurrence.
   In all these varieties venesection must be had recourse to spar-
 ingly; and never, unless where we  have  satisfactory evidence of
 atonic plethora or congestion   It may sometimes be requisite  to
 use the lancet in nasal  hemorrhage, for the head may feel oppress-
 ed and drowsy: and it will  still more  frequently be necessary in
 hemorrhage from the uteius; but the blood abstracted should rare-
 ly  exceed seven or eight ounces; and  in all other varieties, as a 
GE.IL- SP.IL]
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 inelasti-
city 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 subcai bonate; 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
species, may  be had  recourse to with considerable promise.  It
seems, however, to be chiefly  serviceable  in uterine hemorrhage,
where the disease depends upon a laxity of the extremities of the
vessels,  which are therefore  readily  opened by every irritation
applied to the system or to the diseased part.  Whether in this case
it acts altogether as a  bitter, as supposed by  Dr. Cullen, or partly
also as an astringent, it may be difficult to determine; but the ques-
tion is not of importance.
  For other general roborants to  which it maybe 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
• Cl«ss I. Ord. I. Vol. I. p. 111. 120. 
470'
H.EMATICA.
[CL. m.—OK. IV.
 stimulus gives it the irritation it stands in need of, and forms a sa-
 lutary constringent.   A striking case of this kind has already been
 given in treating of accidental hemorrhages from extracting teeth :*
 and it  is only a few weeks ago since the author was requested to at-
 tend in a similar hemorrhage from  the nose   The  patient was a
 lady of about fifty  years of age. of  slender and delicate frame, who
 had for some years ceased to menstruate.  The bleeding had con-
 tinued incessantly for three or four days, during which she had been
 restrained to a very low diet, and allowed nothing but toast and wa-
 ter for her common drink   She was faint, felt sick, and had a fee-
 ble pulse, and must have lost many pounds of blood, though no ex-
 act measure had been  taken.  I gave  her instantly a free draught
 of negus made wiih 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 renew-
 ed every ten minutes.  In half an hour the hemorrhage  ceased,
 and on the ensuing day I found no other  symptom ihan weakness,
 for which a nutritious  but inirritant  regimen was  prescribed.   A
 few days afterwards  the hemorrhage returned from  sneezing or
 some other incidental stimulus, and was restrained, as I was told, for
 I did not see her, by a  recurrence to the same plan. I recommend-
 ed, however, carriage exercise, and an excursion to the sea-coast,
 which has been complied with, and  there has been no recurrence of
 the disease.
  To effect the same intention, I have occasionally advised cardiacs
 combined with astringents in haematemesis, where the discharge of
 blood has been  profuse, and  has continued for some days,  and  the
 patient has become considerably exhausted: and I do not recollect
 an instance in which the plan has proved unlriendly.   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 of  various
 preparations of this metal when employed internally,  the former
 has given numerous examples, and concludes with the following co-
 rollary : " that lead taken into the stomach is a poison; I do not say
 ex proprietate naturae  et tota substantia; but which  is capable of
 doing much more hurt than good  to the generality of men in all
 the known ways of using it; and,  consequently, that it cannot be
 avoided with too much caution."f  In corroboration of which Dr.
 Heberben tells us that  its good  effects are  by no means so  certain
• Vol. I. p 31.
t Med. Transact. Vol* I. p, 311. 
GE.IL—SP. n.}       SANGUINEOUS FUNCTION.
471
as its mischief; and in most cases would be far overbalanced by it.
In the  form of a subaceiate, 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 tinctura saturnina, and the
sugar  of lead ; of the  former,  giving  eighteen drops with three
drops of laudanum 10 a dose, and repeating the dose every four
hours in a little barley-water;  of the  latter, giving one grain with
three drops of laudanum mixed into a pill with conserve of roses;
to be repeated every six hours.  And under both forms he em-
ployed  these  materials with  great  and unalloyed advantages in
hemorrhages of  most  sorts,  especially uterine,  pulmonary, and
nasal.*
   Dr.  Lathamf has since confirmed this practice of Dr. Reynolds in
its fullest degree, and even extended its range; and so little incon-
venience has he found from the  use of the superacetate that he has
employed it " in doses of a grain three times a-day  for six, eight, and
ten weeks successively; usually, but not always, combining it 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 const! ing-
ed, and this seems to  have been the chief mischief; for the bowels
were opened by oleum  ricini and other purgatives in the course of
the day, and the patient was not at all worse for the accident on the
ensuing morning.
   Emboldened by these facts, Dr. Latham  has employed the same
medicine in other diseases in which  irritant astringents and  tonics
seem requisite, as in colliquative diarrhoeas and hectic perspirations,
and  more especially in  that semipurulent expectoration which too
often terminates in pulmonary ulceration and  consumption; and, as
he confidently assures us, with great advantage.   And  he  hence
concludes, that whatever deleterious properties may appertain to
lead in some of its salts  and oxydes, nothing pernicious exists in its
superacetate; in the process for 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. III. Art. XIII.
t VoL V. Art. XXI. 
472
HJEMATICA.
[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 entonic state, it then becomes a disease of debility, and
is to be treated as though originating under the present species.
                      GENUS  HI.


                      MARASMUS.


                        ISmacfatfon.

      GENERAL EXTENUATION OF THE BODY WITH DEBILITY.

Marasmus is a Greek term, derived from  ftm^xiva, " maresco,"
" marcescere reddo."  It was long ago used collectively to compre-
hend atrophy, tabes, and. phthisis; and in employing it therefore in
the present system as a generic name, we only  restore it to its earlier
sense.   The generic character is common to all these subdivisions;
for each is distinguished by a general emaciation of the frame, ac-
companied with debility, and consequently forms a species to maras-
mus as a genus.
   With these species, the reader, however, will find a fourth united,
upon a high authority, with which I fully  coincide,  and  to which
I shall presently advert.   Under the name of clintacteric 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 any
sufficiently ostensible cause, and is occasionally succeeded by a re-
novation of health and vigour,  though it more generally precipi-
tates the patient into the grave.
   Extenuation or  leanness is not necessarily a disease;  for many
persons  who  are  peculiarly lean  are peculiarly healthy ; while
some there  are who take pains to fall away in flesh that they  may
increase in health and become stronger.  But  if an individual grow
weaker as he grows leaner, it affords a full proof that he  is under a
morbid influence;  and it is this influence, this conjunction of exte-
nuation 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 ot some  organs than of others; and it would  be a
subject of no small moment  to inquire into the cause of this, and to
draw up a scale of organs effecting this change from the lowest to
the highest degree.   Dr. Pemberton, in  a 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 since 
ge. in.)
SANGUINEOUS FUNCTION.
/ 3
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 scrofulous  affection of the breast.
In the former we shall find there is a great emaciation ; in the lat-
ter, none at all.—In an ulceration of the small intestines, great ema-
ciation takes place; in scirrhus of the rectum, none—In a disease
of the gall-bladder, which  is subservient to the liver, the bulk of
the body is rapidly diminished; but in a disease of the urinary blad-
der, which is subservient to the kidneys, scarcely any diminution of
bulk  is to be perceived.  In an abscess of the liver, the body be-
comes much emaciated; but in an abscess of the kidneys, the bulk
is not diminished.
  "If we examine into the function of those parts, the diseases of
which do or do not occasion emaciation, we may perhaps be led to
the true cause of this difference of their effect on the bulk.  In or-
der, however, to understand more clearly how the functions of these
parts bear relation to each other, it may be necessary to premise
that the  glands of the body  are divided into those which secrete a
fluid  from the blood for the use of the system,  and those which se-
crete a fluid to be discharged from it.  The former 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 in the
system,  as well  as the glands of direct supply, may be considered
the liver, the  pancreas, the mesenteric glands, perhaps the stomach,
and the small intestines; and the glands of waste are the kidneys,
breasts, exhalant arteries, and the larger intestines."
  The first set are, in feet, the general assemblage of the chylific
organs ; and it is upon their direct or indirect inability to carry into
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
organ of waste  or  of supply ?  The question  may be answered in
opposite ways, according to the hypothesis adopted respecting the
doctrine  of respiration.  They throw off carbonic acid gass. Do
they introduce oxygene or any other vital gass into the circulating
system ?  As an organ of waste we cannot, upon the principle here
  Vol. II.—3 O 
474
HiEMATICA.           [CL. III.—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 spe-
 cies that appertain to the genus before us:—

 1. marasmus atrophia.                 atrophy.
 2. —------climactericus.            decay of nature.
 3. •---------tabes.                     decline.
 4.---------PHTHISIS.                  consumption.

   Ail these follow in regular order, as genera or species in most of
 the nosological arrangements, and are set  down as subdivisions  of
 anucies or marasmus.  By Dr. Cullen, phthisis is regarded as a mere
 sequel of i aemoptysis, upon which we shall have to  observe in its
 proper pace: while atrophia and  tabes are given as distinct dis-
 ea es under t ie ordinary head, only that for macies or marasmus lie
 employs the term marcores as an ordinal term.  The common dis-
tinguishing marks are, that  atrophy is emaciation without hectic
fe\er:  tabes, emaciation with hectic fever; and  phthisis, emacia-
tion and hectic fever coupled with pulmonary disease.  And such,
with the exception of  phthisis, is the distinction continued by Dr.
Cullen in his Synopsis.  Bui 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
the distinction of tabes and atrophia, attempted in  the Nosology,
will properly apply;  as I think  there are  certain diseases of the
same nature, which sometimes appear with, and sometimes without
fever."*   This is  written in  the spirit of candour that so peculiarly
characterizes this great man.   But I cannot thus readily  consent
to relinquish a distinction which has received  the sanction of so
many observant  pathologists, and which appears to me to have a
sufficient foundation.  It is difficult, undoubtedly, to assign a proper
place to all Ahe varieties or subdivisions of those species;  but this
is a difficulty common to many other diseases equally; for we per-
ceive feveis, nervous affections, and  those of the digestive organs,
perpetually running into each other in different varieties, while we
find it convenient  to arrange und  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 ip
various other cases of  general allowance.
• Vol. IV. Part HI. Uook 1. Sect. MDCVHI. 
  GE, ID.—SP. I.]      SANGUINEOUS FUNCTION.               475


                          SPECIES I.


                 MARASMUS ATROPHIA.



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

  The specific is a Greek term deduced from x privativa, and rp^u,
  "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 appli-
  cation of the nutrient part of the blood:  and thus lays a foundation
  for the three following varieties:

  x  Inopiae.                      Blood  innutritious from  scarcity
    Atrophy of want.               or pravity of food.
 0  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 and1
 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 hpnce, 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,-
 under  which the species before us is contemplated in the present
 arrangement.
  But the ordinary demand may not be sufficient for the body, or some
 part of it may be in a state of inordinate wear and waste, as in very
 severe and protracted labour, in which the supply is rapidly carried
 off by profuse perspiration, or in rupturing or puncturing a large
 artery, in which  the same effect is produced by a profuse hemor-
 rhage.  Any oilier extreme or chronic evacuation may prove equal-
 ly mischievous, as an exctssive secretion from the bowels, from the
 vagina,  fro in  the salivary glands, from the breasts; as  where a de-
 licate wet nurse suckles two strong infants.   And hence the origin1
of the second of the above varieties, or the atrophy of wastf. 
4T6
H.EMATICA
LCL. III.—OR.IV.
  Now, in all these cases, wherever the  system is in possession of
an ordinary portion of health, there is a strong effort made by the di-
gestive powers to recruit the excessive expenditure by an 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  forward to  the lungs,
which more rapidly expand themselves for the purpose,to be com-
pleted 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 action which
commences  with the digestive  and reaches  to the assimilating
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
abundance;  and  we hence obtain an explanation of the  variety of
emaciation 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 it  course, or becomes
 loaded with some peculiar acrimony.  And hence another cause,
 or  rather an assemblage of other causes, competent to the disease
 before  us.
   It is from the one or  the other of these sources  that  we are iu
 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 AThoPHY ofdkbility.  The disease under this form is often
 very complex, and it is difficult to trace out what link in the  great 
CE. 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 flaceidity 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  squalid
 eruption.  The breath  is generally offensive, the urine  varies  in
 colour and quantity ; and in infants at the breast, the stools are often
 ash-coloured  or lienteric, or greenish, loose and griping.  The ap-
 petite vanes; in some cases it fails, in others it is insatiable. 
4/8*
HJEMATICA.
[CL. HI.—OR. IV.
  Where these symptoms, or the greater part of them, occur to an
infant at the breast, it becomes us, in the first place, to be particu-
larly attentive to the manner in which it has been nursed, in respect
to cleanliness, purity of air, warmth and exercise : we  have next
to turn our attention to the nurse's milk ; and afterwards to an ex-
amination whether the infant is  breeding teeth, or has  worms, or
there be any scrofulous 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 advisable to change the milk.  It is not easy to de-
tect  all the  peculiarities of  milk that  may render it incapable of
affording a 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 till Saturday night; or who are pressed
into the service of a large manufactory, and have learnt to become
a part of its machinery before they have learnt their mother-tongue ;
there is no difficulty in accounting for the atrophy that so often pre-
vails amongst them.   The appetite does not here  so  much fail as
the general  strength ; their meals are perhaps doled out at the
allotted hours by weight and measure ; but still they are falling vic-
tims to emaciation ;  and are affording proof that  air and exercise
are of as much importance as  food itself; that  there are other or-
gans than those of digestion upon which the emaciation must depend:
and that unless the supply furnished by the food to the blood ves-
sels be sufficiently oxygenized by ventilation, and coagulated by ex-
ercise, the blood itself, however  pure from all incidental acrimony
or hereditary taint, will never stimulate the secernents of the vari-
ous organs to which it travels, to a proper separation of its  consti-*
tuent principles, and a conversion to their own substance.
  In all these cases, therefore, the proximate  cause seems to be
lodged principally in the assimilating powers of the system : and
whenever the digestive organs 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 of 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
influence  of topical  antispasmodics,  and sudorifics continued for
seven years, the writer of this account tells us lhat, he began to get
better—"melius habere coepit."*
* Nos. Med. CI. X. Ord. I. Ex. Collect. Acad, torn, III. p. 693. 
<5E. HI.—SP. I.]
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 halt the bulk  of the muscles of the parenchyma of many of
 the  organs is carried off in the same manner.  Hence therefore we
 are to look for the proximate cause ot 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 smail and it is easily satisfied;
 and  probably digests what is introduced into it.  Yet here the greater
 part of the food  rests ; or rather it passes through the intestines and
 very little into  lacteals,  insomuch  that many of our most cele-
 brated anatomists have thought as I a 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 lives 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
 precincts of  some  other disease, and is to be  governed by its
remedies.  And where the cause is an infirm condition of any part
of the chain of nutritive functions, from the chylific to the assimilat-
ing organs, the same tonic course of medicine that may be  advisa-
ble in the one case  wilt  be equally  advisable  in  the other.  The
bowels should be kept in a state of regularity ; mercurial alterants
may sometimes be required, though less frequently than under one
or two varieties  of  tabes; the bitters and  astringents enumerated
under dyspepsy may be  had recourse lo, according to the peculi-
arity  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. 
410
HJEMATICA.          [CL. IH.-OR. IV
                       SPECIES II.

          MARASMUS  CLIMACTERICUS.

         Brcap of Mature.  Climacteric W&tam.

GENERAL DECLINE OF BULK AND STRENGTH, WITH OCCASIONAL RENO-
 VATION, AT THE AGE OF SENESCENCE, WITHOUT ANY MANIFEST CAUSE.

For the ground-work of this species of marasmus I am entirely in-
debted to Sir Henry Halford's elegant and perspicuous description
of it in the Medical Transactions.   The disease has hitherto never
appeared in  any nosological arrangement, but it has characters suf-
ficiently distinct and striking for a separate species.  In several of
its features it bears a strong resemblance to the marasmus or atro-
phy of old age described under the preceding species : but it differs
essentially in the instances which it affords of a complete rally and
recovery : and if the train of reasoning about to be employed in de-
veloping its  physiology prove correct, it will be found to differ also
in its chief seat and proximate cause.
   The ordinary duration of life seems to have undergone little or no
change from the Mosaic age, m which as in the present day it varied
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 ihe word climax (*A«fce*|) which signifies a gradation, they de-
nominated them climaterics.  They begin with the seventh year,
which forms the first climacteric; and are afterwards regulated by a
multiplication of the figures three, seven andnine, 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. in.—SP. «.]    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 abruptlv recover their sight, and
 throw away their spectacles,  which had been in habitual employ-
 ment for  as long a period; and he has also seen others return to the
 process of dentition, and reproduce a  smaller or larger number  of
 teeth  to  supply  vacuities  progressively pioduced 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.f  Bui 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 gray
 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  apparantly 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 applica-
 tion 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 I have just  adverted.
  The subject is obscure; and it is as difficult perhaps to account
 for either of  these  extremes—for  the  sudden   and unexpected
 decline, as for the sudden and singular restoration.  That the de-
 cline  however is a 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 denominat-
 ed it the Climacteric  Disease.
  Under the last species the author  observed that the great chain
of the organs of nutrition extends from the chylific viscera to the
• Lib. XXXI. Obs. 6.
| Eph. Nat. Cur. passim.
Vol. II.—3 P 
482
HJEMAT1CA.
[CL. HI.—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 parenchyma-
tous structure  of the general frame.   In the disease before  us the
reverse of all this seems to  take place; and for its origin we must
look to the assimilating powers constituting the other end  of the
chain.   The patient falls away  in flesh and strength  before he com-
plains of any loss of appetite, or has any dyspeptic symptoms; which
only appear to take place afterwards  by sympathy.   And that  the
mesentery and lacteals are  not paralyzed and obliterated, as in the
atrophy of old age, is incontrovertible from  the renovation of  power
and reproduction of bulk that form an occasional termination of the
disease.
  In watching carefully the symptoms of this malady, when totally
unconnected with any concomitant source of irritation either mental
or bodily, we shall often perceive that it creeps on so gradually and
insensibly that the patient himself is hardly aware of its commence-
ment.  " He perceives," to adopt the language of Sir Henry Hal-
ford, "  that he  is tired sooner than usual, and that he is thinner than
he was; but yet he has  nothing material to complain of.  In pro-
cess of time his appetite  becomes  seriously  impaired; his  nights
are sleepless, or, if he get sleep, he is not refreshed by it.  His face
becomes visibly extenuated, or perhaps  acquires a bloated look.
His tongue is  white, and he suspects that he  has fever.  If he ask
advice, his pulse is found quicker than it should be, and he  ac-
knowledges that he has felt pains in his head  and chest; and that
his legs are disposed to swell; yet there  is no  deficiency  in the
quantity of his urine,  nor any other sensible  failure  in the
action of the abdominal  viscera, except that the bowels are  more
sluggish than they used lo be."
  Sometimes  he  feels pains shooting  over different parts  of  the
body, conceived to be rheumatic, hut 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; ihere 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. HI.]
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  mare of  the larger  and more
important organs of the  body, as the liver, the lungs, or the heart,
has been weakened or otherwise injured by accident or irregularity,
or is  influenced by a gouty or  other  morbid diathesis, the symp-
toms will assume a mixed character, and the disease be greatly ag-
gravated.  It  is these accidents indeed that  for the most part con-
stitute the  exciting cause, as well as  the  most fearful auxiliary of
the disease ; for, without such,  it is highly probable that the  predis-
position might remain dormant; and  that many a patient who falls
a sacrifice to  it  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 thai 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.  I have seen  it in some instances operate very
rapidly: and  have  my eye at this  moment directed to the melan-
choly fate of a very excellent clergyman, between fifty and sixty
years of age, the father of ten  children, who were all dependent
upon him, and  whose benefice would have  enabled  him, in  all
probability, to provide for  them  respectably had he lived; but
who,  having lost  the beloved mother of his family while lying-in
of her tenth living  child, was never able to recover from the blow,
and followed her to the grave in less than three  months.
  I have at other times  seen the same effect produced as clearly
and decidedly, though with a much tardier step, and  unaccompanied 
484
HJfcMATTCA.
[CL. HI.—OH. IV.
with any sudden shock.   I 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 diminish-
ing, and his nights restless, with little fever, and altogether without
any manifest local  disorder.  The emaciation, with its accompany-
ing evils, nevertheless, increased, the general  disease became con-
firmed, and in about five months he fell a sacrifice to it.
  Occasionally, however, where the climacteric temperament, if I
may so express myself,  is lurking, a very trivial accidental excite-
ment proves sufficient to rouse it  into action.  " I have known,"
says Sir Henry Halford, "an act of intemperance, where intempe-
rance 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 of my readers of this metropolis have heard of, and many of
them have perhaps had the pleasure of  being personally acquainted
with the late  James Cobb, Esq., Secretary to the East  India
Company, the history of whose life, from his intimate and extensive
connexion  and correspondence  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 patronize merit in
whatever rank it was to  be found, ought not to have been withheld
from the world.   In  November 1816 this gentleman, then in  his
sixty-first year, and blest with one of the firmest and most vigorous
constitutions that I have ever 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 all 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 carriage a relief
to  him in  returning home.  His  appetite  diminished, his nights
were less quiet, and his pulse a little  quickend.  At one time  he 
GE. HI.—SP. II.]    SANGUINEOUS FUNCTION.
485
complained of an  inextinguishable thirst, and  voided  an  unusual
quantity of urine,  so as to excite some apprehension of paruria
mellita.  The urine, 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.  Bui 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 advantage 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 recoramen- 
486
HiEMATICA.           [CL. IH.—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 choose, he proceeded without much fatigue to a
 house provided for him  on the borders of Windsor Forest.  The
 distance was now become too  considerable for  me to attend him
 statedly, and I visited him but once or twice afterwards.   He con-
 tinued, however,  to decline gradually, and, in  about a month from
 the time of  his going to Windsor, sunk suddenly under a return of
 the diarrhoea.
  In the progress of this disease medicine will generally be found
 to accomplish but little.  The constitutional debility must be met by
 tonics,  cordials, and  a generous diet: and  a scrupulous  attention
 should be paid to such contingencies of body or mind as may form
 an exciting cause, or aggravate the morbid  diathesis if already in a
 state of activity.   Congestions must be removed where they exist,
 and every organ have room  for the little play that  the rigidity of
 advanced life allows to it: and where aperients are necessary, they
 should consist principally of the warm and bitter roots of resins, as
 rhubarb, guaiacuni, and spike aloes.   In many instances the Bath
 water, and in a few that of Cheltenham, will be also found of  colla-
 teral use: and especially where we have reason to hope that a be-
 neficial  impression has been made on the disease, and that the sys-
 tem is about to recover itself.
  The last  remark I  shall beg leave to offer, I must give in the
 words of Sir Henry Halford himself.  If not strictly medical, it is
 of more than medical importance; and I have  very great pleasure
 in seeing it put forth from so high an authority, and finding its way
into a professional volume.  " For the rest," says he, " the patient
must minister to himself.  To be able to contemplate with compla-
 cency either issue of a disorder 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. ni.—SP. HI.)    SANGUINEOUS FUNCTION.               487


                       SPECIES III.

                  MARASMUS  TABES.

                           decline,

 GENERAL  LANGOURJ DEPRESSION OF STRENGTH, AND, MOSTLY, OF
                      SPIRITS ;  HECTIC FEVER.

 Tabes is  a Latin term of doubtful origin.   The lexicographers de-
 rive it from the Greek tjjjcw, " macero," varied in the Doric dialect
 to txku,—whence Scaliger makes a compound of rxxoGtos, "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 JNn (tab), lite-
 rally u 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  scrofulous taint;
 or an irritation produced  by excess in libidinous indulgences: thus^
 laying a  ground-work for the four following varieties:

      * Purulenta.             Purulent decline.
      f Venenata.             Decline from poison.
      y Strumosa.             Scrofulous decline.
      S~ Dorsalis.              Decline of intemperance.

    In the first of  these varieties  the absorbed pus may be con-
  templated as acting the part of  a foreign and irritating substance,*
  and  as acting upon a peculiarity  of constitution : but unless the latter
  be present, pus will rarely,  if ever, be found to  produce a  tabid
  frame: for, as already observed  under hectic fever, if absorbed pus
  be capable, independently of idiosyncrasy, of inducing a decline in
  one instance, it ought to do so in every  instance; yet this we know is
  not  the  case, since  buboes, empyemas,  and  other apostems and
  abscesses of large extent, have been removed by absorption, and
  yet no tabes has accompanied the process.   It is said to occur more
  frequently where an abscess or a vomica is open  ; in consequence
  of pus becoming more acrimonious  by the action  of the air.   But

   * Armstrong, Diss, de Tabe purulenta. Edin, 1782. Lentilius, Jatxomnemata,
  p. 384. Stuttg. 1712. 8vo. 
488
ILLMATICA.
(CL. III.—OR. 1\ •
 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 inio the blood, for the purpose of inviscating the
 acrimonious spiculae of the r-oisonous 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 produce the waste.  It is a disease, as
 Scheffler has observed, chiefly common to miners and mineralogists :*
 and, next to these, is to be  found, perhaps, most frequently  among
 the labourers in chemical laboratories.
  There are other poisonous irritants which are altogether ingene-
 r:tie 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 stale oi the •svv.em which has apparently  a very  near relation
 to i.Kit of  scrofula, though it is  difficult precisely to identify them.
The variety from this cause is, hence, frequently treated of under
the head of scrofula 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  scrofula, 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 diathesis of a morbid  kind
 demand for their maturity,  unless quickened into development by
 some incidental  cause.  Scrofula 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.
 Scrofula runs its course first, and becomes dormant, though  rarely
extinct; phthisis travels through a term often or twelve years, and
if it do not destroy its victim by the age of  thirty-five, generally
consents to a truce, and is sometimes completely subjugated.   All
*Von der Gesundheit der Berglente. Chemnitz, 1770. 
I.E. HI.-SP. HI ]    SANGUINEOUS FUNCTION.
48S
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 until the close of the scene.
   When the strumous taint is excited into  action in infant life, it
generally fixes itself upon the chylific or chyliferous glands, espe-
cially when they are in a weakly state; most  commonly upon the
mesentery, and to this quarter it often confines itself; insomuch that
" I have frequently," says Dr. Cullen,"found the case occurring in
persons who  did not show any external appearance  of scrofula;
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 conglobate  or lymphatic glands of the mesen-
tery, 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 ;t so rare, that Mr. Cruickshank affirms he never saw such a
stagnation on the dissection of any mesenteric case whatever. And
that a scrofulous 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 scrofulous taint in the blood, that pro-
duces the emaciation in this case, than the  pressure of a scrofu-
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 ip the intestines, and the func-
tions of the liver, were at the same cime 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 III. Book I. $ MDCVI.
       f Vol. I. p. 282. CI. I. Ord. II. Parabysma Mesentericum.
Vol. II.—3 Q 
490
ILEMATICA.
[CL. III.—OK. IV
pressing also on the lacteals and lympalics which enter them and
pass by them."  The appetite is generally good and  often  raven-
ous ;  probably produced by some remote irritation acting sympa-
thetically 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.j   In the strumous enlargemente 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 arc  sometimes  discovered  in the
lacteals 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
oldest historical records that have reached  our own day, and it is
particularly described by Hippocrates under  the name  of <J>©IS12
NOTlAS,||  literally " humid tabes," from the frequent and invo-
luntary 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 newly
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
 he 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 dryness of the tongue.
• Chesneau, Lib. V. Obs. 27.
■j- Journ. de Medicine, 1790. Sept. N. 1.
* Douin, Journ. des Sgavans, 1690.—Munro, Med. Trans. II. Art. 18.
§ Histoire de l'Academie des Sciences, &c. 1684.
K Tltpt tot fffles n*0»v, Opp. p. 539. as also Iltpt Kwa-uy, II. Opp. p. 479. 
GE. III.—SP. III.]   SANGUINEOUS FUNCTION.
491
  Dr. Cullen does not think that the quantity of seminal fluid dis-
charged by undue indulgence can ever be so considerable as to ac-
count for this general deficiency of fluids in the body, and the debi-
lity that accompanies it, and adds that we must therefore seek for
another explanation of these evils. " And whether," says he, « the
effects of this  evacuation  may be accounted  for either from  the
quality of the fluid  evacuated,  or from the singularly enervating
pleasure attending the evacuation, or from the evacuation's taking
off the tension of parts, the tension of  which has a singular power
in supporting the tension and vigour of the whole body, I cannot
positively determine ; but I  apprehend that upon one or other of
these suppositions the emaciation attending the tabes dorsalis must
be accounted for."*
   It is not difficult to trace this result in a less doubtful and  more
direct way.  The sexual organs, both in males and females, have a
close and striking sympathy with the organ of the brain;  and  the
fluid they secrete with the nervous fluid. Whence Willis conceived
that the fluids of both organs are the  same, and  hence expressly
accounts for the debility.f  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, unnerved
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 ha? correctly observed,
the evacuation itself,  even when conducted naturally,  produces a
pleasure 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
interunion.
   It is hence easy to  see that an immoderate excitement of the ge-
neric organs, and secretion of seminal fluid must  we^Ken 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 debilty 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 -^her the  irritation of  a
single blister;  or, which is perhaps mc"e to the purpose, of a small
seton or issue, we can be at no loss tr account for all the evils that
• Pract. of Phys. Part III. B. 1.5 MDCX.
f Parm.Kationalis de Medicament. Operat. Pars. % 1675. 
492
HEMATIC A.
[CL. HI—OR IV
haunt the worn-out debauchee, and especially the self-abuse-, from
involuntary emissions of a seminal fluid, however dilute and spirit-
less, in connexion with the dreadful debility we have just noticed,
and which is  the cause of this emission.   The nervous irritation
which results from this debility is the source of the hectic by which
the miserable being is devoured : and hence the heavy terrors and
insupportable anxiety, corporeal as well as mental, the sense of for-
mication and  other phantasms, the flaccidity of the back and loins,
the withering of the entire body, the constant desire of erection with
an utter inability of accomplishing it, 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 circu-
lation, 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 declVne  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 from
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, astrVjgents,  and the chalybeate mineral waters.
   In strumous decline tfu mode of treatment should run precisely
parallel with that for most cf. the species of parabysma or visceral
turgescence  already laid doyn under their respective heads, and
  • Lewis's Essay upon the Tabes Doisalis. Lond. 1758.—Brendal, Diss, de
Tabe Dorsali, Goett. 1748. 
GE. III.—SP. Ill]
SANGUINEOUS FUNCTION.
493
particularly with that for mesenteric parabysma, to which the reader
may turn.*
  In the treatment of tabes dorsalis,  or decline from intemperate
indulgence, 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
untried 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 invigo-
rating, and a little wine may be allowed after dinner; since it will
almost 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 bathing
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 feeblness, and the
night sleepless with hectic sweats and a frequent involuntary dis-
charge, two grains of opium, or mere if needful, should  be taken
constantly on going to bed; diluted  acids, vegetable or minenal,
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. I. p. 282. CI. I. Ord. II.
  !  See Wicbmann, De Pollutione diurna, frequentiori, sed rarius observati
Tabescentise causa, Goett. 1782. 
494                      H.EMATICA.           [CL, III.—OR. IV.


                        SPECIES IV.

                MARASMUS PHTHISIS.

                       ttonsumjitfim.

SOUGH : PAIN OR UNEASINESS IN THE CHEST, CHIEFLY ON  DECUMBI-
       TURE : HECTIC FEVER:  DELUSIVE HOPE OF RECOVERY.

Consumption, or phthisic as  it is sometimes called by old medical
writers, is by Dr. Cullen contemplated  as nothing  more than a
sequel of haemoptysis, instead of being regarded as an idiopathic
affection:  and his species, which are two, can only be viewed, and
so appear  to have been by Dr. Cullen himself, as separate stages in
the progress of the complaint;  his first species being denominated
phthisis incipiens, and characterized by an absence of purulent ex-
pectoration ; and his second, phthisis covfirmata, 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 hasmoptysis from consumption, rather than
a consumption from haemoptysis.t
  Of the  three varieties we are about to describe, we shall find
haemoptysis a frequent cause of the second, but rarely of  either of
the others.  These varieties I have taken from Dr. Duncan's very
valuable " Observations" on consumption : they are evidently drawn

  • Part I. Book IV. Ch. I. Sect. DCCCLII.
  f Treatise on Consumptive Diseases, p. 45.
  % Sur les Maladies Veneriennes, la Kage, et la Phthisic, &c. 12 Bord. 1733. 
GE. III.—SP. IV.]   SANGUINEOUS FUNCTION.
495
from a close and practical attention to the disease, and arc as fol-
low :

« Catarrhalis.               Catarrhal consumption.
P 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 soft and tickling ; and
there is  an excretion of the watery,  whey-like 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
scrofulous diathesis.^
   In Dr. Duncan's observations, consumption  or phthisis is intro-
 duced as a genus, and consequently the varieties now offered as so
 many species : yet as the tubercular may run into the apostematous
 variety, and the catarrhal into  both, according to the peculiarity of
 the  constitution  and other  concurrent circumstances,  and more
 especially as a common cause  may produce all of them in  different
 idiosyncrasies, the present subdivision will  perhaps be  found the
 most correct.
   Dr. Wilson Philip has formed another variety (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.   " 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 ?
 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 
49G
HJEMAT1CA.
[CL. III.—OR. IV.
 above described, but that of simple phthisis ; and the hepatic affec-
 tion, which is always the most prominent feature of this derange-
 ment in the digestive organs, does not show itself till a late period
 of the disease, and then little, if at all influences the essential symp-
 toms."*
   These remarks show clearly that phthisis in this form is a sequel
 of a  prior  disorder,  rather than an  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 followed
 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
 nothing till the death of the patient; Portal fourteen,} the first two
 of which,  the scrofulous and plethoric,  arc  peculiarly entitled to
 attention, while the rest are drawn from  other  diseases with which
 it is often complicated, or of which it is a sequel.   In Morion 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  peflraps the  greater part
 of the other two.   The terms are those of Hippocrates,  and they
 are thus interpreted by Aretaeus.§
   Phthisis, as sufficiently appears from the last paragraph, is a dis-
 ease of high antiquity as well 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.lf 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.
  f Recherches sur la Phthisis pulmonaire. Par. 1810.
  * Observationes sur la Nature et la Traitement de la Phthisie
2 torn. 8vo. Paris, 1809.
  § Morb. Chron. I. 10.
  | On Consumptive Diseases, Ch. III. p. 20.
  1 Recherches sur la Phthisie pulmonaire. Par. 1810. 
GE. III.—SP. IV.]   SANGUINEOUS FUNCTION.               497

that of thirty-five, though it occasionally anticipates the firstj and
overpasses the second, of these limits; the mean term of its prov-
ing fatal is about thirty;  and the annual victims to its ravages in
Great Britain, Dr. Woolcombe has calculated at fifty-five thousand.*
   The only causes of  phthisis we are acquainted with are predis-
ponent, and those that excite the predisposition into action. Of the
nature of the predisponent cause, we know little more than that it
appears to appertain to a peculiarity of constitution which 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, scrofula, syphi-
lis or measles ; the sudden suppression of a 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 idiosyncrasy, though
the apostematous is less frequent than the rest.   So common is this
complaint among persons employed in  dry-grinding,  or pointing
needles in needle-manufactories, that Dr. Johnstone of Worcester
informs us they seldom lived to be forty, from the accumulation of
the dust of the  grind-stones in the air-cells of the lungs, and the ir-
ritation and suppuration which follows.} 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. 8y»,
Lond.1808.
  | R. Hamilton, in Duncan's Med. Com. XL p. 343.
  4. Mem. Med. Soc. V. 1799. p. 89.
  § Pract Obs. on  the Treatment of Consumptions, 8vo. 1780.
  Vol.  II.—3 R 
498
HiEMATICA.
[CL. HI.—OR. IV
for assistance."*  And, hence, Dr. Fordyce had much reason for
regarding the dust of the streets of London, as  a serious cause of
pulmonic disorders;!  though it is a cause that has been  much di-
minished since the introduction of paving and watering.
  A lodgement of some fragment of a bone in the oesophagus has,
in like manner, been a frequent  cause of phthisis, which has often
been protracted through a long period of time. Thus Claubry gives
a case of this kind which had continued for fourteen years, and the
patient seemed to be in the  last stage of a consumption when he
was fortunate enough to bring up the piece of bone spontaneously,
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, accompa-
nied with cough, haemoptysis, and hectic diarrhoea; and which was
also speedily relieved in consequence of ihe bony fragment 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.  Kence, 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 obser-
vation.  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 Younc
on Consumptive Diseases, p. 206.                                  b
  | Trans, of Soc. for the Improvement of Med. and Chir. Knowledge, Vol. I.

  * Sedill. Journ. Gen. Med. XXXIV. p. 13. 1809.
  § Lond. Med. Journ. VII. p. 120.
  II On Consumptive Diseases, p. 264.
  f Van Swieten, Aph. IV. § 1201. p. 49 
GE. III.—SP. IV.]      SANGUINEOUS FUNCTION.             499

lungs in the tubercular variety of consumption, be, in  every in-
stance, strictly scrofulous, may admit of a doubt; that they are so
in many cases is unquestionable ; and hence scrofula becomes very
generally an exciting, and  not unfrequently, perhaps, a primary
cause, of this disease.  There is a case by Lissardet, of a fatal con-
sumption,  which succeeded to a psora, supposed to have been too
hastily cured; and another by Coeuvet of a more favourable termi=
nation, under similar circumstances, the dartre having re-appeared.
It has occurred more than once to myself, that the lungs have been
attacked during the cure of cutaneous affections, and, in one instance
fatally, even where no hasty mode of treatment had been pursued.*
   The tendency  of the  syphilitic poison to produce phthisis has
been noticed by almost every writer from the time of Bennet, who
particularly dwells upon it;! 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.| Indeed any habitual
irritation in any part of  the alimentary canal seems capable of ex-
citing a sympathetic action in the lungs; and hence Wilson in Dr.
Duncan's Annals, gives a  case of hectic in a  child produced by
swallowing a nail two inches long, which remained  in the stomach
fifteen months, and was  then thrown up, and succeeded by a reco-
very of health.§
   Rapid 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
also is a remark that  has been made by Bennet,t though I do not
know that  it has been supported by a concurrent observation.
   Of all the occasional or accidental causes of  phthisis, however,
frequent and sudden  vicissitudes of temperature are probably the

           • On Consumptive Diseases, p. 269.
           ! Vestibulum Tabidorum, 8vo. 1654. Leyd.
           i De Morb. Thoracis. Lib. II. Ep. Anat. XXI. 43.
           § Vol. 1.1796.
           9 Sedill. Journ. Gen. Med. XX. p. 255.
           * Tabid. Tbeatr. p. 99. 
500
HJEMATICA.
[CL. HI.—OR. IV.
 most common; so common indeed, and at the same time so active,
 as often to be a cause of consumption in constitutions where we can-
 not  trace any peculiar taint or predisposition  whatever.  Several
 hundred cases of phthisis from this cause, among which were many
 fatal ones, occurred in the channel fleet that blockaded the port of
 Brest in April 1800, as is particularly noticed by Dr. Trotter. The
 summer was hot and dry, the duty very severe; and the sailors, 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  the disease
 carries off usually 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 atmo-
 sphere 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, I cannot charge my
 memory with a single instance where any person, labouring under a
 confirmed phthisis, experienced much relief from their use alone."^
   Where a consumptive  diathesis has  once  originated,  it is often
 very evidently transmitted to succeeding generations ; and there is
 great reason  to believe  that the disease  is in a  certain  degree
 contagious.  M. Portal, and a few other pathologists of distinction
 have doubted or denied that it possesses any such property; but the
 apparent  instances of communication among  near relations  and
 close attentive nurses, and especially between husbands  and wives
 who have fallen victims to it in  succession, are so frequent, that its
 contagious power has been admitted by most practitioners  and in
most ages.  Aristotle appeals to it  as  a  matter of general belief
  • Medicina Nautica. Vol. HI. p. 325.
  | Woolcombe (Dr. W.) Remarks on the frequency and fatality of Diseases
8vo. Lond. 1808.—Southey (Dr. H. H.) Observations on Pulmonary Consumn
tion, 8vo. Lond. 1814.                                          v
  * Young ut supri, p. 42.
  § Manual of Health, &c. 12mo. Lond. 1806.
  | Practice of Physic, p. 508, sixth edit. 
GE. III.—SP. IV.]
SANGUINEOUS FUNCTION.
501
among the Greeks in his day :* and it has since been assented to in
succession by Galen, Morton, Hoffman, Vogel, Desault, Darwin,
and most modern writers.
  I have myself been witness to various cases which could  not  be
ascribed to any other cause; and Dr. Rush has given an account of
a consumption manifestly contagious, which spread from the pro-
prietors of an estate among the negroes, who were neither  related
to the first victims, nor had been subjected to fatigue or anxiety on
their account, and amongst whom it scarcely ever makes its appear-
ance.!  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,
 jut 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.
 i'oart Simmons limits it to the tubercular alone; and conceives it to
• Problem, Sect. I. 7.
f Medical inquiries and Observations, &c. Vol. I. 8vo. Phil. 1789.
$ Epidem. v. p. 1142.
§Chron. Dis. i.10. 12.
  < 1. I Ord. I. Vol. I. p. 33 
 502                      HAEMATIC A.           [CL. III.-OR. IV.

 be a distinguishing characteristic of this form of the disease or of a
 predisposition to it.  And he remarks further, that of those who
 are carried off by tubercular  phthisis, the greater number will be
 found never to have had a carious tooth*
   The earliest symptoms of phthisis, in  whatever manner excited,
 are insidious  and  show  themselves  obscurely.*  The  patient is;
 perhaps, sensible of an unusual languor, and breathes with less
 freedom than formerly, so that  his respirations  are shorter and
 increased in number.   He coughs occasionally, but does not com-
 plain of its being troublesome, and rarely expectorates at the same
 time : yet  if he make  a  deep inspiration he is sensible  of some
 degree of  uneasiness in  a particular  part  of the chest.   These
 symptoms gradually increase, and at length the pulse is found quicker
 than usual, particularly  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 decidedly  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 a smell.   In many cases
 it is very scanty; and we  may also add with Aretaeus that  in some
 consumptions there is no expectoration  at all; for in the apostema-
 tous varitey, 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 asiumed 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-white;  " the fingers, to continue the elegant descrip-
 tion of Aretaeus as given by Dr. Young, are shrunk, except at the
joints,  which become prominent; the nails  are bent for want of
 support, and become painful; the nose is sharp, the  cheeks are red,
 the eyes sunk, but bright, the countenance as if smiling; the 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. m—SP. IV.]    SANGUINEOUS FUNCTION.              JOS

  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 greater.  " A few
days before the patient's death, he is frequently unable to expecto-
rate from apparent weakness, and  sometimes dies absolutely suffo-
cated : but much more  commonly the secretion of pus, as well as
 the expectoration, has ceased ; as if the capillary arteries had lost
 their power, or the fluids of the system were exhausted.  There is
 also  sometimes a degree of languid delirium  for some days, and
 occasionally a total imbecility for  a  week or two : though, in gene-
 ral, the faculties are entire, and the  senses acute, the patient being
 perfectly alive to the danger and distress of his situation, and retain-
 ing, even  when his extremities are  becoming cold, a considerable
 quickness of hearing  and  feeling.   The closing scene  is  often
 painful, but it sometime consists in the gradual and almost imper-
 ceptible approach of a sleep which is the actual commencement of
 death."*
   Such is the common progress  and termination of the  disease ;
 but  it varies considerably in the  character and combination of its
 symptoms, and particularly in the  tardiness or rapidity of its march,
 according to the habit or  idiosyncrasy of the individual, or  the
 variety of the disease itself.   Where the constitution is firm, and
 the  hereditary predisposition striking, it commonly assumes  the
 apostematous form, and runs on to  the fatal goal with prodigious
 speed, constituting what among  the vulgar is called, with  great
 force of expression,  a galloping  consumption.  In  this case,  the
 activity of the absorbent, and,  indeed, of every other part of  the
 general system is wonderful:  the whole frame is in a state of
 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*
 cd  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
» Young, on Consumptive Diseases, p. 26. 
504
HJEMATICA.
[CL. HI.—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 consumptipn is as remarka-
ble for its tardiness.  This is particularly the case with the  tuber-
cular variety when not quickened in its pace by returns of haemop-
tysis.  Hoffman gives instances of two or three who lived under the
disease for thirty years:  and in the Edinburgh communications is
the case of an individual who passed nearly the whole  of a long life
under its influence, who was consumptive from eighteen to seventy-
two, and died of the complaint at last.   Of two hundred cases,
however, selected by M. Bayle, a hundred and four died within nine
months, which  may hence be regarded as the mean term.
  Dissections seem to prove that the most  frequent variety of con-
sumption is the tubercular: the tubercles consisting of circumscribed
nodules or indurations, by  Weffer called grandines,*  found indis-
criminately in all parts of the cellular  texture,  but more abundantly
at the upper  and posterior  parts.  They are  at  first very minute,
whitish and opake, like small absorbent glands, but sometimes more
transparent, like cartilage, with black dots in their substance. They
augment by degrees till they are half an inch or more  in diameter;
but in general when they have acquired the size  of large peas they
begin to  soften in the centre, and then open by one or more small
apertures into the neighbouring bronchiae, or remain for a longer
time closed,  and constitute small vomicae, containing a curdy half-
formed pus.  Occasionally  they unite  into large abscesses.!  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 scrofula
selects for its abode a glandular structure, tubercular consumption
cannot perhaps with strict propriety be called  a scrofulous disease:
yet as the untempered fluid contained in  the  tubercles resembles
that of scrofula, and,  more especially as this variety of consump-
tion is very  generally found in constitutions distinctly scrofulous,
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
followed  rapidly upon peripneumony, or taken place in persons of
robust 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 extensive inflammation on
the surface of the trachea, M. Portal has found the whole extent of
the tube lined by a crust resembling bone.   In  some instances,  the
lungs from the accretion of new matter,  have weighed not less
than five or six pounds, which  is nearly four times their ordinary
  • Sepulchr. Boneti per Marget. II. vii.
  ! Young, ut supra.—Portal, Observations sur la nature et la traitement dc
la Phthisie.—Bayle, Recherches sur la Phthisie Pulmonaire. Par. 1810. 
GE. IH.—SP. IV.]    SANGUINEOUS FUNCTION.               £05

weight;  but in others, they have been  so reduced as in the  lan-
guage of the same writer to leave " a vacant space," in the chest;
or, in that of M. Bayle, to be shrivelled  into leather.  On this ac-
count, breathing would be impossible if it were not that the lungs,
in a state of health, are capable of containing ten times as much air
as is received  by an ordinary act of inspiration: and hence are ca-
pable of losing a very large portion of their capacity without suffo-
cation.  In some cases, one lung  has been  entirely  destroyed, and
the office of respiration maintained by the remaining lung alone for
many years.*
   Many ingenious experiments have been invented to distinguish
between pus and mucus, in order to determine the actual nature of
the disease.  Such trials may  gratify the curiosity of the patholo-
gist, but from the variable, and frequently complicated nature of the
expectoration, as well in the most dangerous as in the earlier stages
of the complaint, we can derive little assistance from this distinc-
tion.  Mr. Hunter, as a test, employed muriate of ammonia, having
observed that a drop of pus united with a drop of this fluid is ren-
dered soapy, while neither blood nor mucus is affected by it.!  Mr.
Charles Darwin                            H
             Heu miserande puer! si pua fata aspera rumpas
             Tu Marcellus eris—

proposed a double test of sulphuric acid, and a solution of pure po-
tass.  If, on the addition of water to pus, dissolved in each of  these
separately, there be a powerful precipitation, the matter made use
of is determined to be pus: if there be no precipitation  in either,
 it is mucus.   But the simplest and truest character of  pus, as was
 first observed  and described  by Sir Everard Home, is, that it is a
 whitish fluid composed of globules contained in a transparent liquid :
 that it does not coagulate by heat;  and is  only condensed by alco-
 hol.  The presence of the globules, as remarked by  Dr. Young,
 may be easily determined by putting a small  quantity of the liquid
 between two pieces of  plate-glass.  If it be pus, we shall perceive,
 on looking through it towards a candle  placed a little way eff, 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 surround-
 ed 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-
 cus, there will be no rings of colours;  though a confused coloured
 halo  may sometimes be perceived  by the mixture of mucus with
 blood or some other material.
    Such is the general  history of phthisis.   The pathology and prac-
 tice are  in a most unsatisfactory  and unsettled state:  nor can any
  * Boneti Sepulchr. Lib. I. Sect. 11. Obs. 167.—Parotti, Raccolti d*Opuscoli
scientifici XLVI. p. 275.
  f See Apostema commune of the present Volume, p. lw. 
506
IIJEMATICA.
[CL. Ill—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 scrofula, and is only to be cured by alkalies,
 corrosive sublimate, or other mercurial alterants, employed for the
 cure  of scrofulous affections.*  According to Cullen, though it has
 an apparent connexion  with  scrofula, the analogy  affords us no
 assistance in the treatment, and the remedies for the one are of no
 avail in the other.
   Dr. Rush  contemplated it for the most part as an entonic or in-
 flammatory disease, and particularly in its first stage, though it is
 sometimes accompanied with  a hectic or  even  a typhous fever.
 And  hence  his  principal  remedies 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. J  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
 augmenting  the  perspiration by placing himself near a large fire.
 Mr. May, who adopted the same general principle, seems to have
 postponed the gymnastic part of the process, till the symptoms were
 alleviated, and to  have called in  the aid of medicines, which Sal-
 vadori 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-exercise was to complete the cure.§
• Journ. de Med. 1777.
! Med. Inquir. and Observ. I. 8vo. Phil. 1789. II, 1793. V 1802
* Del Morbo Tisico, 2 Vol. 8vo. Trent. 1787.
§ Lond. Med. Journ. IX.. 1788. 
  GE. III.—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
 fevcr,|| 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 con-
 tinues 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,
 secondly, 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
general intentions by which they seem to have been guided, in the
 • Sur les Maladies Veneriennes, la Rage, et la Phthisie, 12. Bord. 1739.
 ! Essay on the causes, early signs, and prevention of Pulmonary Consump-
an, 1799.
 t Collections for a Materia Medica, 8vo. Pluladel. 1798.
 $ Med. Diet, in verb. Phthisis, Vol. 11. p. 401.
 | Epanetus Hectica. Vol. II. p. 115. 
508
HJEMATICA.
LCL.  III.—OK. 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 vigor
of life, and if the symptoms indicate  considerable  inflammation,
whether in the lungs or bronchiae, such as, in the former case, fixed
pain and weight in the chest, increased by lying on one side, with a
dry but troublesome cough;  and in the latter, a general soreness
rather than pain in the chest, frequent and violent cough, with a
copious excretion of a thin, offensive, and purulent mucus; and,m
both cases, with a full and strong pulse, the fever, though remissive,
making an approach towards  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 otir 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 variety,
bled a man, seventy-eight  years old, three times with the happiest
effect.  Immediately after the use of the lancet, we should employ
small doses of ipecacuan, or antimonial  powder, so as to maintain
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 bronchiae, 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
mucous 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 promise of
success.  Von Helmont first employed this  last medicine  as a
specific for scrofula: but  the only specific influence  we know it to
possess is on the kidneys, and on the action of  the heart and arte-
ries.   It is for this last effect we look to it in the present instance*
the only effect, in all probability, that renders it of any  advantage
in consumption.   In catarrhal phthisis it seems sometimes, how-
ever, 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. HI — SP. IV.]    SANGUINEOUS FUNCTION.               508

augmentation of vascular energy: since, if the vessels be urged be-
yond this, the secretion is hot, watery and acrimonious.
   If sudorifics be ever advisable in any modification of  phthisis, it
is here we  may expect to  find them of use.   Bennet indulged
the hectic morning sweats as a mean of abating the symptoms, and
Morton observes that nothing is gained by checking them.  But it
is perfectly  clear that they  very  greatly add to  the debility, and
never prove critical.  It has been proposed  by  others, however,
to overcome the morbid sweats by exciting a 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 insidious;  and it takes possession  of the fair
and delicate, rather than of the firm and athletic frame, and chiefly
in those possessing this figure who can trace  it in their ancestors
and have hence reason to apprehend an hereditary taint.
  II. Of  the proximate cause of this  predisponent diathesis we
know nothing :  it is generally supposed to have a near  analogy to
that of scrofula; 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  scrofulous indurations.  And, on  this
account, as  there are various medicines, and  a particular regimen
that seems to have a beneficial  effect upon a scrofulous 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 apparently
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 Diabetes, Consumption, &c. 8vo. Paisley, 1808.
        f See Epanetus Hectica. Vol. IT. p. 115. 
510
ILEMATIOA.          [CL. 11I.-OR. IV.
 gree ;*  and Dr. Trotter affirms that among seamen in scrofulous
 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 scrofula,"  says Dr.  Cullen,  " the remedies
 that are seemingly of most power are sea-water and certain mineral
 waters, hut these have generally proved hurtful in the case of tuber-
 cles of the lungs.  I have known," he adds, « several instances of
 mercury very fully employed  for certain diseases in persons  who
 were supposed at the time to have tubercles formed, or forming in
 their lungs : but though the mercury proved a cure for those other
 diseases, it was of no service in  preventing phthisis, and in some
 cases seemed to hurry it on."!
   Nor have any other metallic salts been of more use  than those of
 mercury.   Dr.  Roberts has had  the spirit and perseverance to run
 through the whole range of such  of them as can in  any  way be
 thought applicable to this complaint; and has also had the candour,
 after a sufficient scale of trial in St. Bartholomew's, a  candour  how
 seldom to be met with, to confess that none of them were adminis-
 tered with success. The experimented list consisted of silver in its
 nitrate ; lead in  its superacetate, combined with opium for counter-
 acting its deleterious  effects ; zinc,  in its sulphate and oxyde ;  and
 the precipitate from the sulphate of potash, combined with myrrh ;
 arsenic in the neutral salt formed by a combinallon with potash;
 manganese in its white oxyde, in doses often grains every six hours ;
 cobalt in its black oxyde, in  doses of from one grain to four ;  am-
 moniated copper ; and muriate of barytes.  And with a like want of
 success, he tells us in addition, were employed the vegetable narco-
 tics, aconite, hyoscyamus, stramonium, belladonna, as also toxicoden-
 dron^   We may hence, I think,  fairly conclude  with  Dr.  Cullen
 that, " the analogy of scrofula gives no assistance in this matter."|J
   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  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.
! Medicina Nautica. Vol. III. p. 359.
t  Pract. of Phys. Vol. II. Sect. DCCCCVII
§ Med. Trans. Vol. IV. p. 129.
'  Pract. of Phys. Vol.11. Sect. DCCCCVII 
 GE. III.—SP. IV.]    SANGUINEOUS FUNCTION.               51L

 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 Presei vatif, apparently with ajview of imi-
 tating the great process of nature in her manufacture  of those
 metallic and other mineral waters which have been taken with most
 success,  gives it  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 addi-
 tion, 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 limi-
 tation at all seasons  and hours.
   How  far this  method  may  answer I cannot say from personal
 practice : but the success of M. Lenthois is rendered suspicious from
 its pretended extent;  for he  hereby prevents the  disease, as he
 tells us, if it be not begun, and cures three out of four where it is.
   III. But though in consumptions we can avail ourselves but lit-
 tle of the treatment that applies to scrofula, 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
 scrofula, 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
 succeeded by intense heat and  profuse sweats which exhausted the
 patient,  though they left him in high spirits during the inter-
 missions.* And in such cases,itis 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 Hcctica. Vol. II. p. 115. 
512
HJEMAT1CA.          [CL. HI.—OR. IV
    But this is a plan which cannot be brought into general practice;
 and, in supporting the strength of the system, we are ordinarily
 compelled to pursue a very different course.
    The first means by which we are to aim at accomplishing this is
 of a negative kind ; and consists in saving the frame as much as pos-
 sible from the profuse exhaustion it is daily sustaining, by calming
 the febrile irritation, and checking the colliquative sweats, which,
 as already observed, are never of a critical kind.
    " I have sometimes succeeded very decidedly,"  says Dr. Young
 in a note  to the author, while the present sheet was printing, «in
 checking the sweats by Dover's powder: but I do not know that
 ihe 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-    , i
 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; aud 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. 
CE. IH.-SP. IV.]     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 was 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 state
of convalescence bordering on perfect health ;  and on  his return to
France, pursued the same  plan, with the exception  of the  iron,
which he omitted  as  too stimulant, and found it, in  many cases,
eminently successful, though not in all.* It has since been tried  in
our own country and has often  proved equally advantageous.  Dr.
Roberts has paid particular attention  to its effects;  and, upon a
pretty extensive scale, has been satisfied with them.   One of his
cases was of a very unpromising aspect; and consisted of a young
gentleman, seventeen years of age, whose elder brother had died
of  phthisis two  years before.   The cough, which, in  the morning
                 • Med. Trans. Vol. V. Art. XVIII.
Vol. II.—3 T 
514                      HASMATICA.           [CL. III.—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.  " My patient," says Dr. Roberts, "was at once relieved by the
use of the acid, and in a short time, so lost his complaints, that, by
my advice he discontinued the remedy."*  The acetic and acetous
acid seem to have been employed indiscriminately; over which the
citric, 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 it is
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 form
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. torn. H. 567.  Dufresnoy, in Corvisart Journ
Cent. VII. 531. 1804.                                 '      '
  * Ewell in SeMile. Journ. Gen. Med. XLIV. Hildebrand, id. XXXVI. 
GE. III.—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 Ihe 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 ap-
pears to be rather of the tubercular, or catarrhal, than of the apos-
tematous variety,  these may  sometimes be employed with great
success.  The Angustura bark generally agrees better than  the
cinchona, and to this myrrh and iron may at such times be added in
increasing doses, and particularly as prepared in the  mistura ferri
composita of the London  College.  In the tubercular variety, the
cinchona seldom agrees in any stage : Dr. Cullen conceives never;
and  tells us that even where the disease has assumed something of
an intermittent character, quotidian or tertian, and he has, on this
account, been tempted to try it in free doses, he has in no instances
succeeded so as to establish a complete cure.  "For in spite," says
he, " of large exhibitions of the bark, the paroxysms in less than a
fortnight or  three  weeks after  they had  been slopped, always re-
turned, and with greater violence, and proved fatal."   In the latter
stages of the apostematous variety, and especially when the vomicae
are small and in perpetual succession,  he thinks, however, it may
be of service, in restoring a healthy action, and promoting a secre-
tion  of genuine pus.
  In this last case, and here  perhaps only, we may venture with
success on the use of the  cold  bath.  In a more  irritable state or
stage of the complaint,  the tepid bath may occasionally prove ser-
viceable ; and, where  it does  so, should be repeated three or four
times a week, or even oftener.   Of the effect of the banos de tierra
of the once celebrated Solano  de Luque, I cannot speak from per-
sonal knowledge.  It consists in burying the patient up to the chin
in fresh mould.  It would be most obvious to suppose that this was
designed to act as a tonic, and  check the undue tendency to perspi-
ration  by a protracted chill, but that Van Swieten tells us the smell
of fresh earth  is  serviceable, and  approves of it on this account.
It has  since been recommended by Dr. Simmons and M.  Ponteau.
  Before, however, the hectic, or  the general  irritability of  the
system has so far subsided as  to render tonics  advisable,  our chief
dependence for giving support to the system must be upon diet and
regimen.
  The diet should be of the lightest  kind, 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 most cautious physicians, from the time of the Greeks 
516
H.EMATICA.
[CL. III.—OR. 1V>
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 collatitious 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 upon
a diet of this kind, in conjunction with temperate air and exercise,
the Greek physicians placed their only hopes  of a cure. Whether
it be necessary to pay that strict  attention to the different kinds of
milk which we find in many  writers of established reputation  I can-
not 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 experiments of  Sti-
priaan may be depended upon, mare's  milk  contains  most  sugar
and least cream, butter or caseous matter; and woman's milk most
sugar and least butter and caseous matter next to mare's, with most
cream  next to sheep's.!   Whence mare's milk should be the light-
est of the whole, but less nutritive  than woman's.  According to
Parmentier, however, ass's  milk contains a less proportion of ca-
seous matter than any of the rest.
  Peculiar properties may sometimes be given to milk  by  the food
fed upon; and hence Galen  endeavoured to render  it more astrin-
gent by placing the animal, that was to furnish it, in pasturage, en-
riched for the purpose with  agrostis, lotus, polygonum, and melys-
sophyllum.   And  as  the patient  became convalescent, and  could
bear a richer nutriment, he was allowed to sail down the Tiber and
use the cow's milk of Stabiae, 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. torn. VI. 130, 131. edit. Basil. 1542.
! Comment, torn. IV. Sect. 1211. edit. Lugd. Bat. 1764.
t See Crell's Chemiscbe Annales, § VIII. p. 138. WJ-i 
GE. III.—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 nourishment
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 ihe difficulty  and ex-
pense of acquiring it, it would not  be necessary for us to go to 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 orpyxidatus, 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 pulmonarius, 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 disagreable 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 Fahrenheit,
 and confining himself to this temperature; or he  must seek the
 atmosphere he stands in need of in a foreign climate.   The disad-
 vantage of the former is that though he may support the requisite
 temperature, he cannot conveniently obtain a sufficient  change of
* Med.  Trans. Vol. II. p. 341.
!Hist. de la Society Royale de Medicine. II. 295. 
518
ILEMATICA.
[CL. HI.—OR. IV.
 air, 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 atmo-
 spherical variations, though pathologists have by no means  agreed
 upon a  meteorological standard.   For the patient's residence in our
 own country, the south-western boundery 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.  Southy's inquiry has led  him to conclude that
in Malta, Sicily, and other islands in the Mediterranean, phthisis,
though a rare disease among the natives, does not appear to be  re-
 tarded in those who visit them  for a cure.|  M. Portal dissuades
 from all such trials by affirming that there is no dependence to be
 placed upon them, since he has seen the disease accelerated in Eng-
 lishmen, or those of other northern nations, by a  visit in  quest of
 milder air to  the south of France; whilst in the natives of Langue-
 doc or Provence it has been restrained by a removal to Paris.§
  The whole of this, however, only shows us that very  great care
 is necessary in determining concerning the state and stage of the
 disease, the patient's constitution, and the local features of the situa-
 tion that may be proposed for his residence.   Where, in the com-
 mencement of the disease, there is great irritability, or  an inflam-
 matory  diathesis ; or in its advance the strength of the constitution
 is greatly reduced ; and especially where an obstinate diarrhoea has
 supervened, the fatigues of journeying and of a sea-voyage, and the
 necessary relinquishment of many of those minuter, but still import-
 ant conveniencies, to which  the  patient has been accostomed  at
  * Sir G. Blane, Observations on the Diseases of Seamen, 8vo. 1785.
  ! Account of the effects of Swinging in Pulmonary Consumption, &c. 8vo.
1787.
  $ Observations on Pulmonary Consumption, 8vo. 1814.
  § Observations sur la nature et la traitement de la Phthisie pulmonaire, W
p. 358. 
GE. III.—SP. VI.]     SANGUINEOUS FUNCTION.
519
home will  more  than counterbalance  for all  the advantages  he
might derive from the possession of a milder and more equable at-
mosphere.   The topography of the situation about to be chosen is
of equal importance; for if it be strongly marked by lofty cliffs or
mountains, the air will seldom circulate freely, but rush in currents
in some parts, and be obstructed and become stagnant in others. Such
is the state of Hastings on  the Sussex coast of our own country,
which would 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 suffocated in the latter.   On this ac-
count, it has uniformly been found that  small islands without  any
great boldness of feature, enjoy the most equable temperature, and,
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 distant from it.  This has often
been resolved into the exercise of sailing, or the sea-sickness which
in many instances is  hereby excited.  It is, nevertheless, a distinct
advantage from either,  and  resolvable into the explanation  just
stated.
   Sea-sickness, however, is of unquestionable service in many cases:
 and particularly  in those  in  which a protracted  nausea by other
 means  has already been recommended.  The exercise of sailing is
 useful on another and a very different account.   All motion without
 exertion, or with no more  exertion than  gives a pleasurable feeling
 lo the system, which the Greeks  expressed by the term aeora, in
 stead of exhausting, tranquillizes, and proves sedative.   It retards
 the pulse, calms the irregularities of the heart, produces sleep,  and
 even costiveness.   Hence  sailing on the Tiber was a common  pre-
 scription among the Roman physicians;  and many consumptive pa-
 tients- have  found  great benefit from  long voyages, in which they
 have suffered no sea-sickness, and have been exposed to many varie-
ties of atmospherical temperature. Hence, too, the well-known ad-
vantage of exercise in a swing, or in a carriage,  on  horseback, or
even on foot, as soon as these can be engaged in with comfort:  the 
.j;20
HJEMAT1CA.
[CL. Ill—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
 the beginning; and to such cases of consumption Desault judicious-
 ly limits it.   In the present day it has been revived by Mr. Stewart
 under a variety  of ingenious modifications,  and appears in  many
 cases to have afforded relief:  but the constitutions of mankind must
 strangely have altered  since the days of Sydenham, if the severity
 of horse exercise  could at that period have been employed as a
 specific remedy in consumption of every kind.   Stoll did not find
 it so in the middle of the last century; for he tells us that if a con-
 sumptive  patient mount his h'orse he will ride to the banks of the
 Styx as 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.!
  IV. Another part of the curative process in the disease before us,
 has consisted in endeavouring to subdue the local irritation, and im-
prove  the secretion  from the lungs.   This has been  chiefly  at-
 tempted by fumigations, medicated airs, and expectorants.
  Bennet 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 dependence on an inhalation of
the fumes of  various terebinthinate resins, as frankincense, 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.
! Nat. Med. I.
, Quarin, pp. 162,103. 
GE. Hi.—SP.IV.]     SANGUINEOUS FUNCTION.              521

thinate fumigations have been very extensively tried in consequence
of the warm recommendation of Dr., now Sir Alexander Crichton,
who thought he had perceived  great and decisive advantage from,
the aroma of pitch and  tar diffused through rope  manufactories,
ships, and  other places were  these articles are in perpetual use.
I have tried  this repeatedly by heating a tin vessel of tar over an
oil or spirit lamp, and thus impregnating  the atmosphere of the
chamber with the powerful vapour that arises.  In doing this, how-
ever, we must be  careful not to burn the tar; for in such case the
room will he 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 gass has, in almost every in-
stance, proved  so  stimulant,  and so much increased  the signs of
inflammatory 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
oxygene : since the effect of this gass in destroying the irritability of
the living fibre is known to every one; and it v?as hence a plausible
conjecture  that by being applied immediately to the seat of disease
it might sufficiently subdue ihe 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 engaged
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, ClapierJ
                 i    _____________________                        '—■■    '  *  *'
             • Fourcroy, ARnales Chirur. IV. p. 83.1790
   Vol. II.—3 IJ 
522
ILLMATICA.
[CL.UI.~OR. IV.
 in the Journal de Medicine, relates a case of confirmed consumption
 cured by an habitual residence in a coal-mine;* and expressly states
 that the matter expectorated soon began to assume a more healthy
 appearance, and 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
 residence in cow-houses,! and which was not long since a fashion-
 able mode of practice in our own country.
  Expectorants and  demulcents have, also,  very generally been
 employed for the same purpose;  that of subduing  the disease by
 exciting 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 of vascular action, as in the commencement of the aposte-
 matous and catarrhal varieties, the best demulcents,  and, indeed,
 the only  medicines of this  kind we can employ as palliatives,  are
 the vegetable mucilages, as of tragacanth, quince  seeds or gum
Arabic. Where 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 bronchia as expectorants.  And, where  the
cough is  very troublesome, and  the pain  acute, they should  be
 united with narcotics, as opium or hyoscyamus.
  In a more advanced stage of the disease, and  through the entire
course of the tubercular variety, except where haemoptysis is present,
the expectorants more properly so called have often been employed
with advantage.  One of the oldest of these is sulphur, and perhaps
one of the best; from its not readily dissolving in the first  passages,
it is carried to the rectum, and the skin sometimes, with little alte-
ration ; and hence  gently stimulates both extremities, loosens the
bowels, and excites a pleasing diapnoe on  the surface.  It is in this
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 it with yolk of egg ; and it has maintained its character to
 the present day.   In the tubercular,  or scrofulous variety, as it is
• Journ. Med. XVIH 59.
f Southey, Observations on Pulmonary Consumption, 8vo. 1814
t Neue Scbwed. Abhandl. 1782. P. III. p, 298.
§ Yol. I. pp. 252.382. 
GE. 111.—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 and  resins,  however, have  been more
generally 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 iheir possession of a terebinthinate principle; and
hence they might be used indiscriminately, but lhat 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 :\ 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
diminish 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-
ficatious, 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 to renew them after short inter-
vals.
  Setons, issues, and caustics, however, where the constitution is not
very  delicate,  nor the  habit very irritable, have proved far more
powerful revellcnts, on  account of their more violent stimulus and
greater permanency of action.  The  actual cautery, though much
abstained from in modern practice from its  apparant, 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, torn. HI. p. 237. 8vo. Lyons, 1803.
  f Medicina Nautica, Vol.  IH. p. 325. 8vo. London. 1814.
  ± Therapeutics, Lond. 1758.
  I Practical Observations on the Treatment of Consumptions. Lond. 1780.
  | Radical Cure for a recent Catarrhous Cough, p. 78. 8vo. Lond. 1779. 
524
HjEMATICA.
[CL. HI.—OR. IV.
issues, which he placed in the groins and  hams, under the arms,
and between the shoulders, and kept sweet  by peas and orris root;
and asserts that he found  the use of these  highly beneficial.   Yet
setons are said by those who have employed them to be still more
serviceable than issues.
  The obvious intention is  to produce a revulsion ; and  hence by
transferring the morbid action to a part of less importance, to allow
the lungs to return to a healthy condition.
  Such transfer may, by these means, in some cases, be rendered
total, 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 lime  a  severe rigor from  an  unknown  cause
attacked him,  succeeded by a sweating fit so profuse that his linen
was changed two-and-twenty times in a night, and even this 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 upon  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!  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 conceives again
shortly  afterwards, she renews it: and there have been instances,
in which from  a rapid succession of pregnancies, the suspension has

  • Recherches sur la Phthisie, &c. ut supra.
  f Observations on the Diseases of Seamen, 8vo. Lond. 1785.
  ♦ Vestibul Tabid, ut supra.
  % Recueil d'Observationes de Medicine, &c. Part II. p, 286. Paris 1772. 
GE. HI.—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.

                        £»crojriiula.

lNDOLENT,GLANDULAR TUMOURS, CHIEFLY IN THE NECK; SUPPURATING
 ' SLOWLY, AND IMPERFECTLY, AND HEALING WITH DIFFICULTY ; 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. III. p. 471.
  !  Inquiry into the influence of Situation on Pulmonary Consumption.  By
,i. G. Mansford, &c. 8vo. 1818. 
526
HJEMAT1CA.
[CL. 111.—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 vr^ufm, "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  scrofula  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 scrofula
 and struma,* by regarding the one as a  local, and  the other as a con-
 stitutional and hereditary disease; but although he has been followed
 by a few writers, as well in our own country as on the  continent, 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  scrofula,
 is derived.  Among  horses we meet with it at least as  often, when
 it is called farcy; under which modification it  is propagable by
 transfusion 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 dominates scrofula Chalasis,
 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

         I. STRUMA VULGARIS.             KING'S EVIL.

  The strumous mesenteric decline, in the  present classification
 atrophiasfrttmo«a,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 scrofula; 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.
t Prslect, p. 30. 
GE. IV.—SP. L]      SANGUINE0U9 FUNCTION.              527


                        SPECIES  I.

                 STRUMA  VULGARIS.

                        Zttnfl^liutl.

TUMOURS CONFINED TO THE EXTERNAL CONGLOBATE GLANDS; PEA-
   SIZED, OR CHESNUT-SIZED ; APPEARING IN INFANCY OR YOUTH ; SUB-
   SIDING ON MATURE AGE.

Scrofula 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, 4 and of rather  tall and
slender make.   But where scrofula 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 disese 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. H.  Kortum, Comment.
de Vitio Scrophuloso. Lemgo, 1789.
  Baumes, sur 1c Virus Scrofuleux, &c. 
528
HEMATIC A.
[CL. HI.—OH. IV,
 particularly on the lymphatic system.*  Whether  this 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
 scrofula differs from all other atonic diseases,  since the debility
 and the irritability generally augment in like proportion, and main-
 tain an equal match.
   Early life is peculiarly characterized by an abundance of albumen,
 as its maturity is by an abundance of fibrin.  Dr. Parr ascribes the
 scrofulous 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 scrofulous  tumours by  arguing that, since the
 mobility of the lymphatic system is peculiarly affected and dimin-
 ished, 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 con-
 sist 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 vigor-
 ous elasticity which is the  best prophylactic against scrofula, and
 keeps the scrofulous diathesis most effectually in a state of sub-
jection.  And  hence we find  the common  debilitating powers  of
cold, damp, meagre or unwholesome food, want of cleanlines, and
 a  close  and  suffocating atmosphere,  the  most  usual incidental
 sources of scrofula.
   But for these, a scrofulous 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 be-
come adjuncts with  the  scrofulous  diathesis, scrofula, rathei
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,
or a sudden reverse of  worldly prosperity.  It is also sometimes
• Garn, Kranken geschichten. p. 121.
! Richter, Chir. Bibl. Band. VIII. p. 501 
GE. IV—SP. 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 scrofula 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 scrofulous 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 discoloration 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 dis-
charge  that flows down.  An unsightly lippitude and  eversion  of
the lower eye-lid is  hence a very common result of  a scrofulous
attack on this organ.
  In like manner the  disease, in this unfavourable and aggravated
  Vol.  II.—o  X 
530
ILE MATICA.
[CL. III.—OR. IV.
state, often makes its assault on the limbs, and fixes on the ligaments,
cartilages, or  even the bones themselves; and particularly when-
ever any 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 scrofula
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 scrofulous 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 wc have endeavoured to establish,  that scrofula 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:
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  actuating or acrimonious source.  Yet such a
sourcq 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 acri-
mony 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 arc 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 
GE. IV—SP. I.]       SANGUINEOUS I UNCTION.
531
world, to have resulted from the use of burnt-sponge, burnt cuttle-
fish, shells of all kinds, burnt hartshorn, and even burnt secundincs,
 which last were at one time in  high request, and are to be found
as a sovereign remedy in Schrocder's Pharmacopoeia.*  All these
have in our own day deservedly yielded to the carbonate of soda,or
sub-cat bonate 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
system.   And  the same may be observed  of petroselinum, sarsa,
mezereon, 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 versiculosus:) 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 refutation  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 an-
other 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 scrofulous   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
stimulate violently, we  shall do mischief rather than good, and add
to the debility instead  of diminishing it.   Scrofula is a strictly
• Lib. v. p. 288.
t Prac of Phys. Vol. IV. MDCCLII.
* Id. Vol. IV. MDCCLI. 
,3f                      HiEMATICA            [CL. III.—OR. IV

chronic disease ;  it never has been, and never can be cured rapidly;
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 ones
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
afterwards,  he  gives it the same high  character, and tells us that
he was  induced to try it in scrofulous  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 scrofulous 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 scrofulous  taint as  consisting in  an  acid
acrimony,  are apt to lay hold of this fact in support of their hypo-
thesis.  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  scrofula 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 
GE.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 perhaps operate 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  I can conscientiously say with Dr. Cullen,
that they have often disappointed me, and have not seemed to dis-
pose scrofulous ulcers to heal.
   The local applications, like  the  internal remedies, should be
slightly etimulant; and, where the tumours have broken, usually
consist of digestive ointments combined with the caustic metallic
salts of mercury, zinc, or copper;  and of digestive lotions of  a
dilute solution of alum or nitrate of silver.  These are well calcu-
lated to coincide with the general intention;  but we must not expect
 a sound enre till the morbid impression is set at  rest in the consti-
 tution or utterly extirpated from it.
                       GENUS Y.


                     CARCINUS.

                          Canter.

 iCIHRHOUS, LIVID TUMOUR, INTERSECTED WITH FIRM, WHITISH, DIVER-
  GENT BANDS, FOUND CHIEFLY  IN THE SECERNENT  GLANDS ; PAINS
  ACUTE AND  LANCINATING; OFTEN PROPAGATED TO OTHER PARTS J
  TERMINATING IN A FETID AND ICHOROUS ULCER.

Of this genus there is but one known species:  for Ihe 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 OAVCER :

and it is not necessary to alter the term. 
 534                      FLEMATICA.          [CL. HI—OR. IV.


                         SPECIES I.

                CARCINUS VULGARIS.

                     Common Cancer.

 TUMOUR BURNING, KNOTTY;  WITH DARK  CANCRIFORM VARICES J UL-
            CER, 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  lo 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 ma-
 lignant ulcer of a peculiar  kind :  and  in the  present work it is
 referred 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 (xxpxiiof) is  Creek,  and imports a crab; the
 disease being thus called from the caniriform 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 local,
it is difficult, and perhaps insuperably difficult,  to  say why a blow
on a conglomerate gland, as  the breast for example, should some-
times 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.vonden wahren kennzeichen des Krebsschadens, &c. Goet. 1775. 
t.K.V—SIM.]        SANGUINEOUS FUNCTION.              535

into the  presence  or  absence of a scrofulous 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 ot the
body af-er one, ormore 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 t'aken 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 decendants
 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.  Ihe 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 lo 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 semimum
 to the future race.                            ...    j   •  j
    How far a disposition to  cancer, whether  original or derived,
 may manifest itself by external signs, 1  am  notable to  determine.
 Such an outward  character is by no means constant in the  list ot
 hereditary diseases.  It is perhaps generally visible in those that
 affect the  mind; but far less so in those  that affect the body.  In
 nhthisis, the predominant diathesis has a striking exterior ; in scro-
 fula,  the outward and visible sign is far less distinct, though such
  a sien seems to prevail generally: in gout, there is no specific  ex-
  terior that we can depend upon.  Dr. Parr,  however, has conceived
  that  cancer  has its outward character  as well as  phthisis, and
  that it is indelibly marked in the complexion : " for we have found,
  savs  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 melancholic habits :  a blue
  tint seems mixed with the brown, and is chiefly conspicuous under
  •he eyes, or in the parts usually fair.  This may, perhaps, be a re- 
5S6
ili;matica.
[CL. Ill—OR. IV.
finement without foundation, but we think we have often observed
it.  There is certainly no constitutional symptom  by which 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 handsome
family, all of whom were so fair as to make a near approach to the
phthisical exterior, though none of them have ever exhibited 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 inffammation; and
that even this did not always ensue.t It has been swallowed by dogs
without any mischief.^
  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 primarily
affected,  though they may become tainted from their contamina-
tion with a cancerous  part.  " I never  yet,"  says  Mr. Pearson,
" met with an unequivocal proof of a primary (cancerous) scirrhus
in an absorbent gland."§  And hence we behold a striking differ-
ence between the nature of cancer and scrofula.   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 breast of females, the  uterus, the testes, the glands penis,
the tongue, stomach, cheeks, lips, and angles of the eyes.  The ob-
s.ruction 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 ihe 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. Oiot. in verbo.
f Maladies de la Peau, &c.
* L.e Febure, Kemede, 8tc. 1776.
§ Principles of Surgury, &c. Vol. I. p. 209, kc. 
GE. V.—SP.l.J
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 Llr. Parr, that a milk abscess never becomes a cancer.
Then follow women who are past child-bearing. And lastly, women
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-
fula has been supposed by some to be the result of an acid acri-
mony ; cancer  has by  others been supposed to  be  produced by a
peculiar alkali.  Dr. Crawford, from a  series  of very curious expe-
riments upon the matter of cancer, thought he had ascertained this
to consist principally of hepatised ammonia, and found that this mat-
ter effervesced with sulphuric acid.*   Plouquet, however, affirms,
that it sometimes effervesces with alkalies as  wcll.f   The taste dis-
covers nothing;  for to the tongue it is insipid and mawkish rather
than  acid or alkaline.  Yet Pair, laying hold  of Crawford's experi-
ments, has boldly ventured to assert that the remote cause, or rather
the cause of the  cancerous diathesis, consists in an  excess of am-
monia, with a redundant development  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 of
 insects, and Dr. Adams, who referred it to hydatids* 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
 deposited 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  present day.
    The occasional or existing causes are numerous: but to account
 for their  efficiency it seems indispensable, as we have already ob-
 served, to  suppose the existence of a cancerous predisposition or
 diathesis, since we see the same causes acting  in  innumerable  in-
 stances 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
 tumour incidentally inflamed or irritated; an accumlution ot acrid
 filth in the rugs of the skin, which is  a frequent cause of cancer in
               • Phil. Trans. Vol. I.XXX. 1791.
               f Init. Bibliolh. torn. U. p. 202.
               {Observations on Morbid Poisons.
Vol.  II.—3 Y 
538
HJKMAT1CA.
LCL. HI.—OR. ry.
 the testes, and particularly among chimneysweepers; the hard 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 ebriety
 or irregular living.   With these, severe cold seems also to co-ope-
 rate, as the disease  is generally  admitted to be both more frequent
 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
 tumour by the latter name.   Adhesive bands are now formed in the
 integuments, 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 distended
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
 affords 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
 alternately into the action of the  other.  And not unfrequently the
 lymphatic vessels become affected as high up as the axillse  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
 tumours are prudently removed when the  knife has been resolved 
GE. V.—SP. I.]     SANGUINEOUS FUNCTION.
539
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  lucorrhcea, or menstruation;   sometimes  both.  The
ulcerative  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 of
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 determing 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 ascertained 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 indu-
rated wart; which, from inattention, increases in size, is repeatedly
rubbed off  by the exercise of climbing, enlarges and deepens its
sphere  of irritation, grows  more  malignant, and at length is con-
verted 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 scirrhosity  increases in size and hardness, till the tumour
often acquires an enormous and irregular magnitude, studded ex-
ternally with numerous protuberances, and the shape of the testis,
even  before ulceration, is  entirely lost.  In the progress of the dis*
ease, the spermatic chord becomes affected, and the taint or irrita-
tion is communicated, more or less, to the viscera of the peritoneal
or lumbar cavities.
   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,
._*,;„». ;n,.r»*c» in c;.»#». anri ornriiiatiy evince a cancerous character. 
540
HJEMATICA.
[CL. Ill—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 prodigious 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. 1
   In general, however, a cure is rarely effected 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 be
 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  ace-
 tated solution of ammonia, tar-water, as recommended by Quadrio,
 or an illination of the surrounding  parts with mercurial ointment
 combined 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.
  f Diet, in verb. Vol. I. p. 329.
  * Eph. Nat. Cur. Dec.  I. Ann. IV. V. Obs. 161.
  § Nuovo Metodo per curare sicuramente ogni Canchero coperto, &c  Ve-
nezia, 1750.
    Quevres Postbumes, torn. I. 
GK. V.—SP.I.j       6ANT,l'INT.0rS FUNCTION.                541

ny ; and the latter for supporting the living power, and thus ena-
bling the system to obtain a triumph over the disease by its own in-
stinctive or remedial energy.
  Of the first  class the chief have been the belladonna and hem-
lock, and particularly the latter, which appears  to  have been most
promising.  When Dr. Stoerck  of Vienna published his work upon
the successful exhibition of hemlock in cases of confirmed cancer,
many of which were vouched for by  the baron Van Swieten, every
practitioner was eager for examples  upon which to try the experi-
ment for himself Solanum had been in vogue but was just sinking
into disrepute from its numerous failures : and corrosive sublimate
was the medicine chiefly confided in at St. Thomas's Hospital.  Dr.
Akenside,  who was at this time prescribing the corrosive sublimate
in the hospital, with, what he thought, a gratifying success, imme-
diately exchanged it for the conium,  or cicuta, as it was then called.
He tried it, upon a large  scale, in every stage and modification of
the disease, and at first with the most sanguine expectations.   But
his hopes gradually failed him  as he advanced  in the career of his
experiments; and he was compelled to make very 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
with a degree of candour which entitles it to the fullest confidence,
and appears to deal out the  real truth.  In recent states of the dis-
ease where there was no ulceration, or none of any depth, he asserts
that it often produced a favourable termination, and  gives nume-
rous examples to this effect.   But in inveterate  cases, where the
cancerous  ulcer had made considerable progress,its benefit was very-
questionable : it operated often for  a very  few  days like a charm,
diminished the pains and improved the discharge : but suddenly it
failed to do the slightest good any longer, unless the dose were very
largely increased; upon  which a like beneficial  effect followed:
but unfortunately of equally transient duration.  The dose was, in
many instances, again increased ;  and continued to be so  till at
length the symptoms  produced by the cicuta were as mischievous
as those of the cancer itself, and  Dr. Akenside was  compelled to
abandon it.*
   We arc  hence in some degree prepared for the contradictory ac-
counts of its effects which are  furnished by different  writers.  De
Haen asserts  that it affords neither cure nor relief of any kind ;f
Bierchen, that it aggravates real cancer, though  sometimes service-
able in scrofulous ;t and Lange, that it is altogether inefficacious.§
• Transact, of the C«l. of Phys. of Lond. Vol. I. Art. VI. p. 64.
f Rad. Med. II. 37.
t Loco, citato.
§ Diss, dubia Cicutx vexata.  Helmst, 1764. 
sA2
ILKMAT1CA.
[CL. HI.—OR. IV.
 Fothergill is friendly to its use ;* and Bellf and Fearont recommend
 it'both externally  and internally,  alone  or  in  combination with
 opium.
   For this discrepancy of judgment we have  in  some measure en-
 deavoured to account.  Yet the advocates of the medicine have,
 doubtless, in some instances suffered themselves to speak of it in
 exaggerated terms; and  it is higly 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.  Hap-
 pily the sickness proceeded to a vomiting, and  the poison was re-
jected.   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
 higher proportion.!  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 reports 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. II. passim.
f On Ulcers, Part II. Sect. VIII.
i On Cancers, passim.
§ Mat. Med. Vol. II. Part II. Ch. VI. p. 264.
I lntroduct. to the Theory and Practice of Surgery I
1 Journ. de Med. torn. XXXVII. p. 36.
"• Treatise on the Eyes, passim. 
OE. V.—SP. I.]
SANGUINEOUS FUNCTION.
453
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 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 anamolous action, than by  their sedative
power.
  Of the metallic oxydes that have been brought into use, the only
ones it is 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 Plummer's, 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 martiales
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.
f Observ. Med. B. IV. Lou J 1672.
I Observations on the cure of Cancer, p. 77. 
544
HJEMATICA.
[CL. III.—01?.1\.
   But of all the medicines of this class arsenic has acquired the
highest t;iid 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  commom in the time of Hil-
danus, who ascribes its introduction into  practice  by the  monk
Theodoric,  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 serpentary, to  that of Richard Guy, who
wrote upon the diseasef in the middle of the last century, and whose
boasted arcanum was found to be a  composition of arsenic, sulphur,
hogsfennel (peucedanum officinale,) and arrow's-foot (ranunculus
sylventris.)\
   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 regar'led it as a specific.§ Smalz
thinks it serviceable.||  SchneiderU  and Justamond declare it  to be
useless, though the latter employed it locally as an escharotic. Hil-
danus** and Deliusft assert it to be injurious ; and SchenckiJ 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 that 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 eveu
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.
  f Essays on Scirrhous Tumours and Cancers. 1759.
  t Ritcher, Chir. Bibl. Band. V. p. 132.
  § Kemede eprouve"  pour guerir radicalement le Cancere occulte, et mani-
feste ou ulcere\ 8vo. Paris.
  (I Seltene chirurgische und medicinische Vorfalle. Leips. 1784. 8vo.
  •] Chir. Geschichte, i'hiel. V.
  •• Account of the  methods  pursued in the treatment of Cancerous and
Scirrhous Disorders-. Lond. 1780.
  tj Dissert. Observat. et cognit. nonnulia chirurt;\ Fasc. VI.
  t* Observ. Lib. II. N.304.
  §§ Blumenbach. Bibl. Band, VIII. p. 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 ii permanently  in subjection is the existence of a pre-
dominant diathesis of seme other kind   How far the remark may
have been  made  antecedently I  know  not, but from a pretty close
attention lo the subject  within my own sphere of observation,  I
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 applicat.ons
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
gass, 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 Rosier's  Jour-
nal ; and an easy  and convenient mode of application has lately been
contrived by  Dr. Ewert of  Bath.   Dr.  Crawford, however, for  ihe
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 g've 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 animals being feigned to expire
in agonies as the poison of the ulcer was drawn out, and its  surface
assumed a better aspect.  Bouffrv. who was a witness to their use)
  Voi  II.—3 Z 
546
nJLMATICA.
LCL. HI.—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."f
   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 it 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 postively 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. torn. LXII.
t G. Woodfall's Edition, Vol. I. p. •241. 
CE. V—SP. I]    SANGUINEOUS FUNCTION.
547
  The die is cast almost, if not altogether, irrecoverably: and all we
  can hope lo accomplish is to  postpone the fatal result, to mitigate
  the sufferings of the day, and-soften the harsh passage to the tomb.




                       GEMS  VI.


                            LUES.

                      ©eucrcnl  Disease,

  ULCEUS on the genitals, INGUINAL buboes, or both, after impure
   coition; succeeded by ulceus in the throat, copper-coloured
   spots on the skin, hone-pains and nodes.

 The term lues is derived from the Greek Xvu,« solvo, dissolvo"—
 " to macerate, dissolve or corrupt;" and agreeably to the common
 rule of expressing the power of the Greek v by a Roman y, should
 be written lyes, as in the case of Lyssa, and Paralysis, both of which
 are derived  from  the  same root;  but lues has been employed so
 long and so generally,  that it would be little less than affectation to
 attempt a  change: and in allucinatio,  or hallucinatio,  from the
 Greek xXvu or «At/<n«, we are supported by a similar example of de-
 viation from the common  rule.
   It  appears to have been known  to the world  from an early age,
 as I have remarked on the running comment to the volume of No-
 sology,  that  acrimonious  and poisonous materials  are,  at times,
 secreted by the genitals, capable of exciting local, and perhaps con-
 stitutional  affections,  in  those who expose  themselves  to such
 poisons by  incontinent sexual intercourse.   Celsus  enumerates
 various diseases of the sexual organs, most of which  are only refer-
 able 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 miner evils, in the fearful contemplation
 of so  new and monstrous a pestilence;  to various modifications of
 which most of the anterior and slighter diseases of the same organs
 seem to have been loosely and  generally  referred;  as though there
were but one specific poison issuing from this fountain, and conse-
quently but one specific malady.  On which account, much confusion
has arisen in the history and description of this disease ; and syphi-
lis, its most striking species, though commonly admitted, as we shall
see presently,  to be comparatively of recent origin, is by Plenck,*
* Beobachtungen, fcc. H. 
548
HJEMATICA.
[CL. III.—OR. IV.
Richter,*  Stoll,t  and  other  writers of considerable  eminence,
regarded as of far higher antiquity;  asserted by Lefevre de Ville-
brune| to  have existed  eight centuries before the  expedition of
Columbus  to America, and by De Blaguy§ to have been extant in
the Mosaic age.
  The keen and comprehensive mind of Mr. John Hunter first called
the attention of practitioners to the idea of different poisons and dif-
fcrent  maladies;  and the subject  has since  been  pursued by Mr.
Abernethy with a force of argument, and illustrated  by a range of
examples, thai 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
primary and secondary symptoms  that often vary in their  mode of
origin, succession, and termination, from those of genuine syphilis,
though in many instances they make a striking approach to it; and
to which, therefore, Mr. Abernethy has given the name of pseudo-
syphilitic diseases.
  Whether these really constitute distinct species, issuing from dis-
tinct sorts of infection, or are mere varieties or modifications of one
common species produced by one common morbid secretion, has
not yet been sufficiently determined.   In this ignorance upon the
subject, it is better, for the present, to regard them in the latter, as
being  the more simple view; and  with  this  preliminary explana-
tion the expediency of allotting the two following distinct species to
the genus lues will, I think, be obvious to every one.

     1. lues syphilis.                      pox.
     2.     ■ syphilodes.                   bastard pox.
• Chir. Bibl. Band. I. Sect. ii. p. 163.
f Praelect p. 94
i Itetz Annates, IV.
§ L'Art de guerin les Maladies Veneriennes, Sic. 
GE. VI.-SP. I.]      SANGUINEOUS FUNCTION.               549


                        SPECIES I.


                    LUES  SYPHILIS



 ULCERS ON THE GENITALS CIRCULAR, UNGRANULATING, THICKENED AT
   THE EDGE; THOSE OF THE THROAT DEEP AND RAGGED; SYMPTOMS
   UNIFORM IN THKIH PROGRESS ; YIELDINGTO A COURSE OF MERCURY J
   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
 blotches.  It was also very generally called French Pox, as being
 supposed to be a gift to Europe from the  French nation.
   There is  some uncertainty  concerning  the origin of the specific
 term syphilis, which was probably however invented by Fracastorio
 about the close of ihe fifteenth century, from the Greek <rv and <pite*>,
 importing "mutual love;" for such  is the title by which he has
 designated his celebrated and very elegant poem  upon this very
 inelegant 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;! 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, " fei£ omnem, Asiae ver6, atque Aphricae, partem

  • De Henry, la Methode curatoirede laMaladie Venerienne, vulgairement
apellee la Gnusss Verolk, &c.  Paris, 8vo. 1552.
  •J- See especially Meiner, Sitten des mittel alten.—Stumf,  Schweitzer Chr«-
nick, Lib. XIII.—Stettler, Schweitzer Chronick, Lib. VII.—Sprengel, Ges-
cbichtederArtzeneykunde,Theil. II 
550
H/EMAT1CA.
[CL. HI.—OR. IV.
non  parvam occupavit."*  The writer proceeds to notice the dis-
pute that was then hotly engaged in as well concerning the nature
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 tevris ignota profanis
           Exoritur: primus, regi qui, sanguine fuso,
           Instituit divina, sacrasque in montibus aras,
           Sypuilus ; ostendit turpes per corpus achores,
           lnsomnes primus noctes, convulsaque membra
           Sensit, et a primo traxit cognomina morbus;
           Syfiui.idemq.ue ab eo labem dixere 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 Berlin, a clergyman of Ruffach, and an eye-witness
of the disease on  its first appearance, assigns  it  a very  different
origin ; and in his history of the Italian expedition of Charles  VIII.
declares it to have been a punishment inflicted by the  Almighty on
this  monarch and his subjects, in consequence of his having carried
toff the Duchess Anne of liretagne 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 the
report.  Of the two who thus contributed to spread it, one  of them,
Goncalve 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 concuetudine 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 certainly
reckon Antonio  de  Herrera.  He fixes  the return  of Columbus
at ihe period above  specified; and is  very particular in  detailing
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
received; the preparations which were immediately made for his
second voyage;  the speed with which these preparations were ac-
complished ; and the instructions given to him  on the occasion.
Yet not a hint is added that his crews were unhealthy, that the new
recruits had any dread of the plague, to which, had he brought it
home, they must have known they were about to  be exposed, nor
a  single instruction to be provident of their health in this respect.
He took leave of the royal pair with  every mark of  distinction, the
whole court accompanying him to his house, as well at the time as
when he quitted Barcelona.  " Despidose," says Herrera, " de los
Reyes, y aquel dia  le accompanb toda la Corte de palacio a su casa,
y tambien quando salid de Barcelona"*
   Linneus 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 firht 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 Fracastorio's poem,
was not only  called the plague, but was, in truth, a specific  fever
attended with most violent putrid symptoms, together with car-
buncles,  buboes and oiher glandular abscesses, which discharged
a malignant  sanies, often fatal, and even, when  recovered from,
leaving the most melancholy  murks 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 prohibited all medical assistance,  and inhumanly left to the
effects of their own licentiousness.  For Mr. Arnot  gives the copy
of an  order from  the privy-council  of Edinburgh, which equally
banished to the  island of Inch-Keith those who were affected with
the disease, and  those who undertook to cure it.f
   lly  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
limes; for very severe cases are now much rarer,  not only in pri-
vate practice  but even in public hospitals, than they were thirty or
forty years ago.
" Umt Gen. de las Indias occidcntales, Decad. I. L. LI. C. v,
f History of Edinburgh, by Hugo A not, Esq. -Itu. 1789.
i  Kccbachtungcn, &c. p. 17-?. 
•o2
ILEMATICA.
[CL. III.—OB.V.
   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 genera-
tions, 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 here-
after 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 violenc*, 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 aibvvcr as a prophylactic.
  Syphilis shows itself under two distinct sets  of symptoms, local
and constitutional, the latter of which is commonly, but noi always,
a sequel of ihe 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
disease 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, which 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, lhat 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 irri-
tability, 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 inflamed 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. IV.—SP. I.]     SANGUINEOUS FUNCTION.               555

more acutely painful, so as to render walking troublesome ;  and if
not opened by the lancet, generally bursts by the time it has reached
the size of a pullet's egg, and discharges a copiou s quantity of pus
from a single hollow.   In a few instances, the supp urative inflam-
mation does not follow, and the tumour as it augments acquires a
scirrhous 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 blenorrhoea, or gonorrhoea as it is
commonly called, or the purulent discharge  from the eyes in puru-
lent ophthalmy.
   This was at one time mistaken for a genuine gonorrhoea, and the
two diseases were very generally regarded as only different modifi-
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 fo 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 dis-
tinction 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 proper 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 slough, and surround-
ed with a hard, red, elevated and erythematous outline.
  The mucous membrane of the conjunctive tunic of the eyes
next suffers in the  same way, and displays an inflamed surface with
  Vol. II.—4 A 
fr54
HJEMATIOA.
[CL. III.—OR. 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 desqnammate 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 checks
  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 is not 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  -f
contamination.  We have already seen that the primary, or  local   t-
signs generally manifest themselves within four or five  days: and,  *
where the constitution bas become infected without them, wc 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.f
  • Hahnemann, Unterricht f iir Wundarzte iiber die Venerischen Krankhei-
ten.8vo. Leips. 1789.
  t Facts illustrating the effects of the Venereal Disease. By William Hey,
Esq. F. R. S. 1816. 
OE. IV.—SP. 1.]
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 pioduccd  by receiving infected breath,!
and lying in a bed which had been antecedently  occupied by a
person  labouring under  the disease/:t in some 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 tootb,§ by
bleeding or scarification  with an infected lancet,|| or by the attend-
ance of an infected  midwife,1i  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 examinution,
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,"
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 first received  it, they not
being apt to suspect an infection 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
durch gemeinschafftlische Trinkgeschirre.  Waissenfels. 1817.
  + Keid, Diseases of the Army, &.C
  t Horstius, opp. II. p. 315.
  § Watson, Medical Transactions. Vol. III. p. 325.
  I Gin-mner,die Venerischen Krankheiten, &c p. 165.
  \ Act. Nat. Cur. Yol. YU. Ob». 75. Vol. IX. Obs. 94. 
556
ILEMAT1CA.
[CL. HI.—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."*
   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 consc-
quently have been the source of contamination.
   Such however is  the unsusceptibility 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, Schenckf 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 inirritablc  lo 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, and tried 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 very  large doses with less incon-
 venience in syphilis than in almost any other disease.   From  its
 palliative effects its 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. III. Art. xxi. p. 297.
f Observ. Lib. VI. No. 21.
* Mauriceau, II. p. 100. 377.  Eph. Nat. Cur. Cent. HI. IV. Obs. 18.
§ Reisen, III. 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 list 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,  »milax, and one or two species of  asclepias,  or swal-
low-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 of use 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.
   They 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.f
 Upon a very large scale he has met with very great success ; though
 he candidly acknowledges that  the  secondary symptoms of the
 disease have required a longer time to be overcome under the new
• Mat. Med. Part H. Chap. V. p. 200.
I Edinb. Med. and Surg. Journ. No, LIU. p. 84. 
558
HAiMATICA.
[CL. 111.—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
 connexion 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 upt igtit 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 the leaves, and Dr. Stoerck, with his usual liberality,
 assigns it an extravagant praise,  informing  us  that  it effectually
 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 fairer
 claim to notice.  It is a drastric 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 ii 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 principle 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.t  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 die tarn  flammulam Jovia
posse tuto exhiberi. Vienn. 1769.
  t Crato, Epist. v. p. 293. 
GK  IV.—SP. I.]      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 forms
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 nymphae a netumbo.
  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.t   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 its 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 il 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. 1. CL 1. Ord. II. Gen. I. p. 257.
  f Argricola, Comment, in Pappium. Num. 1643.—Ochmen, Fcldchirurgus,
8vo. Fr. and Leips. 1750.
  t Seethe Report of A. S. Duportal, M. D. and Tit.  Pelletier,  Apoth. An-
nales de Chemie. torn. LXXV11I. p. 38. 
560
H£MATICA.
[CL. HI.—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 of 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 ad-
dition of opium and camphor, which gives 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
some 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  antidote does.
not depend upon  its being a sialagogue 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-
monical salts of the  blood,  which he  fancies to  have a close  affi-
nity 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 ofas-
:. Med. Part II. ch. XVII. p. 443-450.—See also the present Work, 
 I.E.VI.—SP.I.]     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 were 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
 scouring 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's gummy solution of
 mercury has  been applied to a sound person  without occasioning
 either a chancre or any other syphilitic symptoms. And it has hence
 been supposed that mercury neutralizes  the syphilitic virus and pro-
 duces a third and harmless substance. As it has been further suppos-
 ed 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
 satisfactorily 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 o£ 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  every other form.   It was the leading
 article of most of  the  secret remedies that were sold for the com-
 plaint, and  especially of Keyser's 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 aromalics and opiates; and hence they gradually
 yielded on the continent to Plenck's solution, which still holds a con-
 siderable 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 carry-
 ing it into effect;  for the older practitioners who employed larger

  • Des Drag£es ou Pilules de M. Keyser. Par  Richard de Hautesierck. Recu-
eil d'Observations du Medicine desriopitafix MiJitaires, &c. Paris. 176*.
  Vol. II.—4 B 
56ii
HASMATICA.
[CL. III.—OR. IV.
doses did as much mischief to the constitution by the antidote as it
had received by the infection.   If calomql 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 wjjjl 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
lo 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 bubo 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-  i
portion  of  the ointment or other preparation must be regulated by
the violence or duration of the complaint.   Where salivation is de-  ,,m
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 skill)
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 bowela
be loosened with some gentle aperient, and the irritability oppose^
by sedative and mild cardiacs as camphor, guaiacum, and sarsapa-
rilla; and particularly by the mineral acids.
• Vol. H. CI. III. Gen. VI. p. 209. 
GE  VI.—SP. II.]     SANGUINEOUS FUNCTION.               3q\3


                       SPECIES II.

                  LUES SYPHILODES.

                       Bastard JJoj:.

ULCERS INDETERMINATE IN THEIR CHARACTER ; SYMPTOMS IRREGU-
  LAR  IN THEIR  APPEARANCE; USUALLY YIELDING SPONTANEOUSLY;
  VARIOUSLY AFFECTED BY A COURSE OF MERCURY.
                                           i i

I have already observed at the opening of the present genus that
the species before us is designed to include a multiplicitly 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. Bv 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  givjj something of a body to the outline, we are still
in want of  distinctive characters, and cannot determine with  any
degree 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 it is
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 not
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
giving proofs of a spontaneous cessation;  they are irregular  and
• Treatise on the Venereal Disease.
t Snrgical Observations on Diseases resembling Syphilis. Lond. 1810. 
I
s64                      IIASMATICA.           [CL.III.—0R.1V

desultory in their  symptoms; seldom require  a  mercurial treat-
ment, and arc often exasperated by it.
  In illustration of ihese remarks, I might refer to the observations
of those who have been  attentive  to the subject on a large scale -r
but I refer more particularly 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 arc 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 sixpence, and fre-
quently 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, ihe
fifth  is the only one that  answers to  this description.  These arc
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 number 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 are
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 9uckled 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,
were afterwards washed with calomel in lime-water: they gradually
healed.  Bo'h 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. VI—SP. 11.)
SANGUINEOUS FUNCTION.
563
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 smBENSor sivens, literally rubula, or raspberry eruption;
and which seems to be a variety of lues rendered hybrid by passing
through a constitution already contaminated with genuine rubula or
yaws.   The local 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, ratfnr 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 the 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) 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 very Infectious Distemper, &c.
      f C»scs ia Surgery ; to which is added an Account of the Sibbens. 
Sob
1L/EMATICA.
[CL. I1I.—0R.1V
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  ' ro-
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.

                     aElcjriiau t^Sftttt.

SKIN THICK, LIVID, RUGOSE, TUBERCULATE ;  INSENSIBLE "TO FEELING*;
  EYES FIERCE AND  STARING; PERSPIRATION HIGHLY OFFENSIVE.

The Greeks denominated this diseae elephas  of elephantiasis,
because the skin of persons affected with it resembles that of the ele-
phant in thickness, rupgedness, 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
brain-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,  howewer, 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 throw*
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 connexion which does not in reality exist.
  My attention was  particularly called to this subject about five or
s'rx 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 PUNCTION.
56?
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 forme this morn-
ing, 1 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 elephan-
tia?)—The thick leg  is described  by Haly Abbas,!  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.
  "  F.n 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
accurately with the leuce of the Greeks, and the vitiligo (species 3.)
of Celsus.—If the Hebrews did not apply the term (translated)
leprosy, to several affections of the skin (such as  the  scaly lepra
grscorum, ihe psoriatis of Dr. Willan, and the leuce, which I sus-
pect they did :)  this  leuce or baras would seem to be the  unclean
leprosy described in Leviticus, Cap. XIII.**
  "  If your knowledge of the oriental languages will enable you.
together with your knowledge of  these diseases, to disperse some

  • See Avincen. Quart III. or Lib. HI. Fen. III.  Tract. HI. Cap. I.
  f Theorice' Lib. VIII.  Cap XV., and Practice Cap. IV.  In which passage*
the translator has used the word Elephantia, and not Lepra,  like the other
translators.
  4 Theorice, Lib. VIII. Cap. XVIII.
  $ Lib. III. Fen. XXII. Tract. I.  Cap. XVI. or XVIII.
  | Ad Almanzor. Lib. IX. Cap. XC1I1.
  ^ Lib  II.  Cap. XXVI.
  *• This  is the opinion of two learned eld Germans, Leon. Fuchs, in bis
Parado&a Mediciniae, Lib. It. Cap.  XVI.; and Gregor. Ilorst. in his Kpist. to
Hopner, inserted in his Observationes Medicniales, Lib. VIII. Obs.  XVIII.—
And  Sennert seems to be of the same opinion, Pract. Med. Lib. V. Part 1
Cap. XL. 
568
HEMATIC A.
[CL. m.—OR. IV.
 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:
  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 flumina Nili,
         Gignitur ^Egypto in media neque  praeterea usquam.'
         High up the Nile,  mid Egypt's central plains,
         Springs the Black Leprost, 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
 seemshighly probable, namely 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 njrv2f J7J3 " the
stroke of the scourge," and which  affords, without question,  the
most ancieni record in the world, composed in  a mixt language of
 Arabic and Hebrew; and if we add to this the still more powerful
 argument 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 Egypt, Persia, and India, in all which regions the disorder is
about equally common.   Yet  the Arabic name is not  elephas  or
elephantiasis, but juzam, literary " disjunction, amputation," vul-
garly, 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 members,  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 elephas,
and which they sometimes contract to fil, 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 juzarn, could only translate dal fil by elephan-
 tiasis also.   And  hence arose that confusion of the two  maladies
 which was continued to the present moment, notwithstanding  the
• De Rer. Nat. VI. 1112. 
GE. 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 {Xtvxi,) 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 va-
rious 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 cast  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, elephantiasis 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 //, as you state, to the
swelled leg.   This  is some apology  for  the  appropriation of the
Creek  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. Batcman adds, that he apprehends the term elephantiasis had
also a reference to the magnitude md duration of the disease,inde-
pendently  of the appearance of the skin.   And it is very probable,
as the malady was likewise sometimes denominated leontmsis, 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 Aretxus tells us, in describing
it, that " it is disgusting to the sight, and in all respects terrible like
the elephant," Aviccnna 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. II—+ C 
570
HJEMAT1CA.
[CL, HI.—OR. IV.
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 ARABICA.         ARABIAN ELEPHANTIASIS.
2._____________ITALICA.         ITALIAN ELEPHANTIASIS.
3.----------,--- ASTURIENSIS.      ASTURIEN ELEPHANTIASIS
                        SPECIES I.

            ELEPHANTIASIS  ARABICA

        Arabian* 3Elq>Uauttams.  Macft aqjrosaj.

 IUBERCLES OHIEFLT ON THE  FACE AND JOINTS; FALL OF THE HAIR,
  EXCEFI" FROM THE SCALP : VOICE HOARSE AND NASAL: CONTAGIOUS
  AND HEREDITARV.

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
Spanish 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
only," says he, " am a daily witness of communication between le-
pers and other people, without the least  ill consequence, but know
several  instances  where a  leprous  husband, (afflicted  with  the
Arabian leprosy or elephantiasis) married to a sound wife, has coha-
bited with her for a long series of years, and  had  several children
by her, without her having contracted the least symptom  of the dis-
order, although the children  have  inherited it; and vice versa be-
tween 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, influ-
enced 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, 
 LE. VII.—SP. I.J    SANGUINEOUS FUNCTION.               571

 lions of the patient: yet great deformity is advancing upon his ex-
 ternal make.   The alae of the nose  become swelled and scabrous,
 and the nostrils are preternaturally dilated ;  the lips are tumid; the
 external  cars, particularly the  lobes, are enlarged and  thickened,
 and beset 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 voice becomes hoarse and obscure;  the external sensibili-
 ty is  obtunded 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
 ulcerations, 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 clothes, 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 mise-
 rable progress is nearly a transcript of  the description just given.
 The patient is  so worn out with fatigue and melancholy, as to be
 often  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 diapho-
 retics, 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 »f a Residence in that Island, Vol. I. p. S95. 6v<*
Edin. 1818. 
572
HiEMATICA.
[CL. III.—OR. IV.
mercurial alteratives still more  so;  though  salivation  appears to
have been uniformly mischievous.  Even the lobelia has had its 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  embro-
cating the body  with spirit of wine or rum, or exposing it to a va-
pour-bath of mastic, olibanum, 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
syphilis, 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, often proved 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 lately
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 places,
or in  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 particularly
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 others
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
almost deprived the patient of his sight. There was a want of sensa-
•  Medico-chirurg. Trans. Vol. X. 
GE. VII—SIM.]      SANGUINEOUS FUNCTION.              573

tion in the extremities;  and a loss of motion  of  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.  1 he
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 ol
proof spirit.  By the latter end of  May, the tubercles were consider-
ably softened :  by June 28,  they  were dispersed ;  a red scurty el-
florescence alone remaining behind, which in ten days lost its florid
 hue, and peeled off leaving the cuticle sound  and clean.   < 1 he  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 eyebrows; 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
 patient is tvrxexa xx, r W««,* of a healthy skin and colour.
                       SPECIES II.

             ELEPHANTIASIS ITALICA.

                  Xtaliau Elephantiasis.

TUBERCLES CHIEFLY ON THE BODY AND LIMBS, SOMETIMES DESRUAM-
  MATING : GREAT TENSION OF THE SKIN : VERTIGO : BURNING, LANCI-
  NATING PAIN IN THE HEAD: MELANCHOLY, AT FIRST  REMIT!TNG,
  AFTERWARDS FIXT, TERMINATING IN ALIENATION OF KIND: HEREDI-
  TARY.

For a knowledge of this species we are almost exclusively indebted
to the Italian  physicians who have generally given it the name of
pellaera or pelagra.  The first writer upon the subject appears to
11 Xen Francis Frapolli, a physician of Milan whose work-in
inorbum vulgo Pelagram dictum," was published at Milan in 1771,
ami whS expresses himself doubtful whether the disease, though
not antecedently described, is not referred to occasionally by earlier
wrtors  aUhouBh he does not think that the pilarella, as the syphi-
Hs ^s'called when it proved depilatory to the chin and eye-brows
*■ Med. Trans, ut supra. 
574
HiCMATK'A.
[CL. HI.—OR. IV.
was the disease in qucstion,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'Oleggio,
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.f  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 wc 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'Oleggio; while by
Odoardo it is attributed  to a scrofulous  habit.J 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, listlcss-
ncss, 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.|| But this assertion is not confirmed by  the history of other
pathologists:  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 primaveravolgari-
ment dette della Pellagra.
  t De Pelagra morbo in Mediolanensi Ducatu  endemio.
  * D'una spezia particolare de Scorbuto.  Venet. 1776.
  $ Da quadam Impetiginis specie, morbo apud nos in rusticis nunc frequen-
uon, vulgo Pellagra, nuncupata, 8vo. 1790.
  g Baldinger, Journ. XXVI. p. 9. 
QE. VII.—SP. II.]
SANGUINEOUS 1UNCTION.
575
disease : in which the itching grows more pungenc; 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
vitac 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
lust  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
  he disease has not  advanced beyond the reach of recovery.




                        SPECIES III.

         ELEPHANTIASIS  ASTURIENSIS

                  &sturtan SGlcjihanttasfs.

 TUBERCLES CHIEFLY ON THE HANDS AND FEET; CRUSTAC EOL'S,
   DESQUAMMATING ; 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 it
 is only worth while to notice the points in  which they differ.
 Upon the whole, we may observe that all the species coincide in
 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, Observationcs. Ann. I, II. III. Mediol. 178* 
 5rii                     h.ematica.           lcl in.—OK. n

 by thick urine, double  vision,  and a peculiar mouldy smell of the
 sweat.   In the Astrian 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.
   This  species constitutes the  Astrian leprosy of Thicry, Vander-
 monde,  and Sauvages ;  but genuine leprosy is not a constitutional
 complaint; and the present is its proper place.  As the  tubercles
 desquummate, the skin  appears of a glossy  leprous red, and the
 disease  is hence called by the Spaniards  Mal  de la Rosa.
   The  causes are extreme  poverty and its  attendants,  filth, 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 suc-
cess  here.
                     GENUS VII1.

                   CATACAUSIS.

           CKennal (Eomtmsttuilits of the iJooi>.

The peculiar state of the constitution which lays a foutidation 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
Nosology, is Dr. Young's Medical Literature, in which it is noticed
under the Greek name here applied to it, derived from k«t«k«i«
" exuro."  One only species  has hitherto  been  discovered as
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.—SIM ]     SANGUINEOUS FUNCTION.               >77


                        SPECIES I.

               CATACAUSIS EBRIOSA

                  Xuebviate  eatacausfs.

 111E i ONSTITUTION INFLAMMABLE  IN CONSEQUENCE  OT A LOMO  AND
  IMMODERATE USE  OF  SPIRITUOUS  LIQUORS :  THE  COMBUSTION
  EASILY EXCIIED OR SPONTANEOUS.

 In this wonderful malady, 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 combustible
 substances immediately adjoining it, as linen or woollwi furniture.
 The body, in several instances, has been found actually burning,
 sometimes with  an open flame flickering over it;  and  sometimes
 with  a smothered heat or  fire  without any  open  flame whatever;
 while the application of water has occasionally seemed rather to
 ouicken 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.                    ...     .    «•     v
   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 insta"Cee'b^V°^a
 dead, and more or less completely burnt up;  the burnt  parts


            •  Bartholin, Act. Hafn. I. Obs. U8.
            f FouqueU Journ, de Med. torn. LXVIIL
    Vol. II.—4 D 
578
HJEMATlCA.
[CL. Ill—OR. IV
 being reduced to an oily, crumbly, sooty,  and extremely offensive
 matter.  "I confess," says M. Pierrc-Aime-Lair,* " that these ac-
 counts at first appeared to me to be worthy*bf very little credit, but
 they are presented to the public as true by men whose veracity is
 unquestionable.   Bianchini, Maffci, Rolli, Le Cat, Vicq d'Azyr, and
 other  men  distinguished by  their learning, have offered a 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
 numerous examples ; as also a variety of foreign journals of estab-
 lished 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 inter-
 esting ; but in a general course of medical study, the phaenomenon
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.

                          Sctirug.

LIVID SPOTS ON  THE SKIN FROM EXTRAVASATED  BLOOD;  LANGUOR
      AND LOSS OF MUSCULAR STRENGTH ; PAINS IN THE LIMBS.

Porphyra is in Greek what purpura is  in Latin,  literary " the pur-
ple or livid disease."  The latler 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. VIII. 
GE. IX.]
SANGUINEOUS FUNCTION.
5'79
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, or any language  whatever ; but an  intolerable barbarism,
derived, as is commonly supposed, from the German  compound
Hchar-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
distinct, 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 :

   1.  PORPHYRA SIMPLEX.
   2.  —--------H-iEMORRHAGIA
   3.  --------- NAUTICA.
• Synops. of Diseases, p. 102.
j- On Cutaneous Diseases, Ord. III. p. 453.
PETECCHIAL-SCURVY.
LAND-SCURVY.
SEA-SCURVY. 
5U
H/EMA11CA.
[CL. 111.—OR. IV
                        SPECIES I.

                PORPHYRA SIMPLEX

                    Pttrctlu'al Sntrtog.

SPOTS NUMEROUS, BUT SMALL  AND FLEA-BITE-SHAPED :  CHIEFLY IS
       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 fevers. 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 tney exist in
any considerable degree, they lay a foundation for those minute ex-
travasations which constitute the present species; and  which may
take place even 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 ebullitioncm ; 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, wilh fetid brea»h 
UE. IX.—SP. I.)      SANGUINEOUS JUNCTION.
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:
* Pulicosa.                        Exhibiting from the  first  a
  Simple Pulicosc Scurvy.            rrolicose,  or  flea-bite ap-
                                     pearance.
• Urticaria.                        The flea-bite spots preceded
   Nettle-whcal Scurvy.               by reddish,  rounded  and
                                     nettle-sting   wheals,  but
                                     without  the  nettle-sting
                                     itching; fugacious and mi-
                                     gratory.
   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 constitu-
tional affection; for there is usually a loss of appetite, and an edema-
tous swelling of the hands and ankles; while the spots arc 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 pro •
cess of cure.
                       SPECIES II.

          PORPHYRA HEMORRHAGICA

                      Hana^Sfccurbg.

SPOTS* CIRCULARjOF DIFFERENT SIZES J OFTEN IN STRIPES OR PATCHES,
  IRREGULARLY SCATTERED OVER THE THIGHS, ARMS AND TRUNK J OC-
  CASIONAL HEMORRHAGE FROM THE MOUTH, NOSTRILS OR VISCERA;
  GREAT DEBILITY AND DEPRESSION OF SPIRITS.

This species is sometimes marked  by febrile paroxysms, with \a 
582
ILEMATICA.          [CL. III.—OR. IV
 liable intervals, but usually occurring in the evening.  It has no re-
 gular or staled termination.  Dr. Willan has found it  run on  in
 different 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
 ihe  limbs, so that business or even  company  is found  fatiguing.
 After this there are often shivenngs, 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,
 intestines, and uterus.  The hemorrhage is often profuse and can-
 not easily be restrained, and  is accompanied with anasarcous swell-
 ings. 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
 produced by habitual gluttony, and particularly by an habitual and
 immoderate use of spirits;  which  have the strongest tendency to
 render  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
sufficiently clear; and where  these occur, antecedently to the tonic 
GE. IX.—SP. II.]      SANGUINEOUS FUNCTION.'.              5S3

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 difficult
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.  1 he 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
time 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,  wc 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
causes 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 entirely
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 uncleanliness, not only in the public streets
but also in private houses.
  All these are  also causes  of sea-scurvy;  and we find from the 
584
HJEMATICA-
[CL. HI.—OU. IV.
description of Willis and others, that they produced conjointly very
similar  effects;  and that  the  mortality hence  ensuing was very
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 century
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
salad till a gardner was sent for from  the  Netherlands to  raise it:
nor were the  most common articles of the kitchen-garden, such as
cabbages, cultivated till this reign.*  And  such was ihe 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
ji law was formerly in existence which made it a capital offence to
burn it  within the city walls; so that it was only 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 exe-
cuted for this offence in the reign  of Edward the First.—We learn
also from Davenantf that heaps of the most noisome filth were suf-
fered to accumulate in consequence of the imperfection of  the pub-
lic sewers; and that particular places were marked out and assigned
for such accumulations, 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 metropolis:
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,! published in the
year 1703. " Agri Somersetensis, uliginosi magna parte et depres-
si, kerem crassum et humidum trahentes, incolae, maculissubnigris,
 ulceribus malignis, crurum dolore, respiratione difficili, lassitudine
 spontanea, nervorum debilitate, hydrope, gangrami, et istiusmodi
 aliis scorbuti exquisiti signis creberrime divexantur."
   The picture is strongly and fearfully sketched, and  precisely

   • Anderson's History of Commerce.—Sir G.  Diane's article, Med. Chir
 Trans. IV, p. 96.
   f Page 351.  ed. 1673.
   * De Arthritide Symptomatic* 
QE. 1X.—9P. II.)    SANGUINEOUS FUNCTION.
855
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,0 from whom I have often had occasion to quote,
and whose words I would always give rather than my own,l< which
has constructed our sewers, and widened our streets, and removed
the nuisances with which they abounded, and dispersed the inhabit-
ants over a larger surface, and taught them to love airy apartments,
and  frequent changes of linen;  has  spread  itself likewise 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 adverted with the
attention  it deserves to the prodigious mortality occasioned 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 <jf 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 patients
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 offen-
sive state the day after he was admitted."
                       SrECIES III.

                PORPHYRA NAUTICA.

                       ara^Sruron.

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

This species is denominated sea-scurvy, not from its being exclu-
sively limited  to mariners and extensive  fleets, but from its being
most common to persons thus occupied, and raging in such situa-
tions with the  most  fatal havoc.  For the peculiar, as well  as  the
general, causes which produce it at sea may also operate on shore,

            • Dr. Hcbtrden, Med, Tram. Vol. IV. .\.  VII,
  Vol. II.—4 E 
58G
HJEMAT1CA.
[CL. HI.—OK'. IV.
and have at times operated with merciless ravage in besieged garri-
sons, and among armies reduced to short provisions, or of unwhole-
some  k n is, and worn down by fatigue, anxiety, and exposure to  a
damp atmosphere.  Such seems to have  been the condition of the
Roman army under the command ofGerrnanicus, as related by Pliny;
whose account of the disease that preyed upon it, though  vague and
unsatisfactory, coincides wiih the general appearance of sea-scurvy.
We have similar de?criptions in. several of the expeditions that took
part in the  Holy Wars, and  particularly that of St. Lewis as related
by Joinvillc.  We may hence conclude th-.it sea-scurvy is not a dis-
ease of recent  times  alone;* though  it does  not appear  to  have
attracted any very general attention till the melancholy  result of the
famous voyage  of Vasco de Gama  in 1497.  The  spirit of maritime
discovery was at this  time in full  vigour  and activity; the Portu-
guese, 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 diminishedfrnergy 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 bluish or livid spots, which do not rise
above it; and these spots  often coalesce in large blotches, particu-
larly in the legs and thighs.   About  the  same period, old ulcert
often break out again, and the slightest mercurial preparation quickly
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 siate 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.
Lmd.  The  calves of the le^s fall away, with sometimes an irregular
• Compare Kichter, Pr. Disquisitio in Hippocraticas Seorbuti antiqiutrtcs, fcc. 
GE. IX.—SP. HI.)    SANGUINEOUS FUNCTION.               587

hardness, and at length become edematous: while the bones them-
selves, no longer supplied with a sufficiency of  calcareous earth,
give way  at the callus of fractures; and  those  which  have been
forrnly broken and rc-united, become again separate at  Ihe  line of
re-union.*
  The last stage is truly distressing.  Blood is frequently discharged
from the intestines, bladder, and other organs.  The slightest mo-
lion brings on faintness, and often  immediate death.   Catchings of
the breath and  syncope,  slightly  and occasionally, indeed,  found
earlier, 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 lime,  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  moit 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 Pnngle to
the present day.  Dr. Cullen was so convinced of the active power of
these two causes, that be 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 dis-
solve the crasis  of the animal  fluids, and  render them  putrescent,
though, in a living state,  they hardly ever proceed to an actually
putrid stage.  And applying these general remarks to  the disease
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  conse-
quently dissolved, or putrescent state of the blood, which constitutes,
in his view, the proximate cause of scurvy.t
   In other places, indeed,  Dr. Cullen supposes not merely that the
introduction of an unusual quantity of salt  into the blood ms\  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 appearing, unless where salt meats had been employed,
• Aitken, Essays on several important subjects in Surgery, &c.
I Tract, of Phys. §§ MDCCCXll, MDCCCXIII. 
588
HJEMATICA.
[cl. m.—or. ry.
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  cuiing the dis-
ease are those which are the most alkalescent, and make the nearest
approach to an ammoniacal property, as the alliaceous and tetrady-
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 pecu-
liarly generous and  stimulating: and we have  one  instance of  its
having occurred in a young woman who had subsisted almost wholly
on tea.
  In like manner, though the fluids of the  body are loose and  inco-
agulable, the muscular  fibres  are equally loose  and incontractile;
so that the latter, as justly observed by  that excellent practical
writer, Dr. James Lind,f are as 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-
scurvy;  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  ventilation,
neglect of cleanliness,  and very generally short  rations, or an un-
wholesome 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 digestive

             * Prac of Phys §§ MDCCXCII, MDUCXCHI.
             t Treatise on the Scurvy, &c. p. 277. 
GE. IX.—SP. m.]    SANGUINEOUS FUNCTION.
589
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 carbon 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 diminished,
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 pro-
portionably of a  darker colour.
  On this account Gintariner,* 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 necessary 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 of the dis-
ease and in effecting  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-scurvy 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 extraordinary circumnavi-
gation  of Captain 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 objects 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. Band. III. p. 527. 
59.0
HJSMATICA.
[CL. M.—OR. IV.
   The regulations and management adopted by Captain 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  Pringle's additional  remarks upon it,t it has
 laid the chief  foundation for the present mode of treating this disease,
 and particularly of providing against its attack.   The principles it
 unfolds should be canvassed by the nautical student in the commu-
 nications  themselves, in conjunction with  the latter works of Sir
 Gilbert Blane| and Dr. Trotter.§
   With the auxiliaries of cleanliness, proper ventilation, a dry atmo-
 sphere, and fresh provisions, the medical treatment of sea-scurvy is
 sufficiently simple, and the disease is found to yield easily.   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  bf 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 roqt 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 Discourse upon  some late Improvements of the Means for preserving
the Health of Mariners, &c. 4to. London.
  t Treatise on the Diseases of Seamen.
  § Medicina Nautica. 
GE. IX.—SP. III.]   SANGUINEOUS FUNCTION.
591
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.*
  Captain 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 Captain 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 surprise 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
gasses 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 be com-
* Observations on the Diseases in long Voyages, &c. 8y». 
 592                    HiEMATICA.          [CL. HI.—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 «o 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 ah? 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 wdrds of Dr. Trotter, " baa
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.0
                      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 pecu-
liar diathesis; and the  last  is productive of severe, and often fatal
constitutional disorder.  These species are as follow:
                                      ANEURISM.
                                      VARIX.
                                      BLUE-SKIN.
                       SPECIES I.

              EXANGIA ANEURISMA.

                        Aneurism.

              PULSATING TUMOUR OF AN ARTERY.

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
1.  EXANGIA
2.  --------
3.  ---------
ANEURISMA.
VARIX.
OYANIA. 
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 aneurismal
tumours not  unfrequently occur in different arteries of the same in-
dividual, simultaneously or in succession.* De Haen gives a singular
example of this in a boy of seventeen :f and Lancisi has conjectured
this diathesis to be produced by gout, rheumatism, 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 in-
duced 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:
       * Cysticum.         Encysted aneurism.
       C Diffusum.         Diffuse aneurism.
       y Varicosum.       Varicose aneurism.
       ^ Cardiogmus.      Aneurism of the praecordia.
   The true or encysted variety, forming the aneurism by dilatation
of  M. Petit,1f 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 m some parts,
         • Saporta, Dissertatio de Tomoribus.
         f Rat. Med. iv. 2. § 7.
         # De Subitanea\ morte, 100.
         § De Aneurismatibus.
         H Syst. of Sur. Vol. I. Ch. iv. p. 196.
         1 Memoires de 1'Acad. des Sciences, 1736.
Vol. II—4 F 
 J94                      HJEMATICA.           [CL. UI.—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 walla
 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, scrofulous 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 piobable  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 aneurism of the femoral artery.t
 It has commonly been said that  the compress should never amount
 to more than an easy support to the weakened and  enlarged organ 4
 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.§
" In the  rebellion  of 1798, an  officer received a wound from a
 bayonet,  which grazed  the  left carotid  artery,  and  produced a
• Reinesius, Schola Ictorum Medica, p. 321.
f Trans, of Medico-Chirurg. Soc. Vol. IX.
$ Cagnior, Desauft, Journ. de Chirurg. torn. II.
§ Chirurgische Vorfalle.  Band, I. 44. 
GE. X.—SP. 1.3
SANGUINEOUS FUNCTION.
595
pulsatory tumour: this was kept down by a spring collar, and at
length disappeared.  Many years after, having lived rather freely,
he died dropsical.  Previous to his  death, he had  a most violent
palpitation of the heart, and discharged by stool immense quantities
of blood. The heart was not found  enlarged, but the cavity of the
left carotid was almost entirely obliterated."
  In connection with pressure, great  benefit has also frequently
resulted from  keeping the amount of the circulating fluid  in a
diminished state by occasional venesections, purgatives, and a spare
diet.   Morgagni  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
easily than in others: and hence it seems sometimes to have taken
place spontaneously, of which an example is given by Mr. Crampton,
in the Medico-Chirurgical  Transactions ;t and by Mr. Ford,  in a
journal of an earlier date.f
  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.  I may,
however, observe  that in cases of  necessity it has  often been  per-
formed 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.  The  first proved unsuccessful from the  long
standing and size of the sac, which pressed with  perpetual irritation
on the larynx and pharynx, exciting frequent fits of 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 otten
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. XVII. Art. 30,31.
f Vol. VII. p. 341.
* Lond. Med. Journ. Vol. IX.
§ Desault, Journ. de Chirurgia, p. 321. 
596                     ILEMATICA.           [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, continued ; fresh blood was perpetually poured
forth; in six weeks the tumour on the hip became enormous, the
thigh was rigidly contracted, the ham 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 sup-
posed to be dead or dying, but the artery could not be traced.  At
this critical moment Mr. Bell ran the bistoury upwards and down-
wards, 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 operation-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 elon-
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
distention, 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 cardiogmus  of Galen  and Sauvages;
 the aneurisma praecordiorum  of  many authors,  and the  polypus
 cordis of others.  The symptoms are usually found on dissection to
 proceed from an  aneurismal  enlargement  of some  part of the 
                        )

                         ■-V,:

GE. X.—SIM]       SANGUINEOVS riTNCTION.               597

substance of the heart, or the largej >essels in its immediate neigh-
bourhood, sometimes accompanied yuth ,uid  perhaps produced by,
a polypous concretion ; and  sometime* >j>ihout any such substance
whatever: and where the larger vessel* »re 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 ob-
served, 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  ot
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 rig bt auricle, of
which an example is given  by Bartholin ;*  or the left ventricle, as
stated by Dr. Douglas ;f but more usually in the arch Of the aorta.
   In many of these cases we can trace the cause ; for the aneurismal
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 t his manner
 been rendered  altogether  impervious,  the  circulation being con-
 tinued 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 ; afid 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 meais 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 ae re-
 lieved by camphor, volatile alkali, and tincture of hyoscyamusV
    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 gitfes a
 description of one of the superior trunk that ascended as high af the
 maxilla ;|| and Teichmeyer of another that burst into  the  pericar-
   _________________.___________________________________________________________,_________________________.____________________________i_____

         • Act. Hafn. IV. Obs.  47.
        | Phil Trans. Vol. XXIX. 1414-1416.
        * Cooper and Travers's Surgical Essays, I. p. 125.
        S De Sed. et Caus. Ep. XXI. 49. XXVI. 31-33.
        K Mem. de I'Acad, RoyaJe des Sciences a Paris.  Ann, 1707. 
598                     H-CMA/lCA.           [CL. III.—OR. IV

dium.*  From their extent sndpressure, they often erode the carti-
laginous and even bony sdittance of the ribs; and  La Faye relates
a case in which a part of the sternum as well as two cartilages of
the ribs were hereby detfroyed.f  In an enormous aneurism of the
abdominal aorta, Morgagii  mentions that the posterior wall of the
artery itself was destroyed, the neighbouring 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.

             ,               Wavi?.

                soft, livid tumour of a vein.

This diseas*e is to veins what the true or encysted aneurism is to
arteries.  1* he  coats of ihe veins  are preternaturally dilated, and
more in wr*ne 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 oi 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.
  Thi»affection mostly occurs in the veins of the lower extremities
in consequence  of their being the most dependent part. They often
arise-cpontaneously in persons of lax fibres; but are far more fre-
quently a consequence of undue fatigue, strains, cramps, or pressure.
Th^ most frequent cause  is a pressure of the fetus in pregnancy
against  the external iliac veins, in consequence of which the blood
aieends with  difficulty from all the veins below, which become dis-
Mnded 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.
Thiu» Tozelli discovered it, after death,  in the vena azygos ;\\ and
* Dissert, de stupendo Aneurysmate brachii, &c. Jen. 1734,
f Phil. Trans. N. 287.
* De Sed. et Caus. Morb. Ep. XI. 26.
§ Ep. XVTI. 25-27.
| Prima Raccolta di Osservazioni medici, Firene, 1752. 
GE. X.—SP. II.]     SANGUINEOUS FUNCTION.
599
 Michaelis describes one that terminated fatally in the jugular vein.*
 They are also met with in the spermatic veins ; and in this position
 hare 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 oponeurosis; 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 cephalic
or cephalic-median vein, as of  bleeding in the basilic or basilic*
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. XLIII. Art. 34.
  * Von dem Suscrlichen drtfichen Gebranche des Kalten WasserS, &c. Leips.
1784. 4to. 
600
i \ AM ATICA.         [CL. «.— OR. IV.
that when injured or icndered otherwise imperfect, they srt often1''
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. Huntei
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
bleeding ;  and particularly in one case that occurred in St. George's
hospital, 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
divided 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. Vol. III. p. 430.
t Id. Vol. V. p. 210. 
GET X.—SP. III.]     SANGUINEOUS FUNCTION.
SOI
                       SPECIES III.

                  EXANGIA CYANIA.



skin more or less blue; lips purple;  general hebetude,
                       and inactivity.

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 eliminations.  From the Greek
xuxvot, or  " blue,"  Dr. now Sir Alexander Crichton, in allusion to
the colour of the skin, by which it is peculiarly  distinguished,  has
elegantly  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 import-
ance to  the functions of life and growth, and hence no more blood
seems  to  circulate through them than  is necessary for their de-
velopment and health.  The florid, or decarbonated blood, instead
of being received  from the lungs by  the pulmonary veins, is re-
ceived  from  the placenta  by  the venae  cavae, and passes for the
most part at once into the general circulation, chiefly by means of
the foramen ovale, by which the two ventricles  communicate, and
partly by means of the ductus arteriosus, by which the pulmonary
artery  at  this time  anastomoses with  the  aorta; that portion  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
cavse 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
partly perhaps by the absorption of oxygene from the respired  air
(for the subject is still open to controversy,) it acquires its perfect
elaboration 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,
the venous or black-blood  must wholly, or  in a very considerable
degree, be thrown  back again into the  general  circulation, instead
of passing to the  lungs:  and the minute arteries on the surface,
   Vol. II—4 G 
60S
HJEMATICA.
[CL. Ill—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,
flews 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 venous
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 thrownintothe arterial circulation as to give a blue or purple tinge
to the lips of the skin generally, all the functions will be performed
feebly, 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 far-
ther 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 chlrurg. Privatgesellschaft in Kopenhaeen.—Bertholin.
Anal. Reform. Lib. LI. cap. 8.                       * 
OE. X.—BP. HI.]     SANGUINEOUS FUNCTION.
S05
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
appears 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.f
   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  vein&4
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 li^ht diet,
and attention to the state of the bowels.  In  one instance, and only
one, I have seen the  blueness of the skin gradually disappear a few
months after birth, and the child grew stout;  evidently proving that
morbid  communication, whether in  the foramen or the arterious
duct, was closed by a natural process.
                       GENUS  XI.

                     GANGRjENA.



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

Gangr.ena, sphacelus, and necrosis, have been hitherto used in very
indefinite senses; sometimes as synonyms, and sometimes as different

     * Observationes anatomico-pathologicx, Lugd. Bat 1777. 4to.
     f De Caus. et Sed Ep. XVI.
     * Phil. Trans, 1805, p. 228.
     % Plate VI. p. 21. 
604 s
H.EMATICA.           [CL. IIL—OR. IT.
stages of a common disease.  And even in this last view they have
rarely preserved their  gradations witn any thing like  an uniform
consent; the whole of them sometimes expressing the highest, and
sometimes an inferior  degree of the  malady, they equally import.
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 insensibility and shrivelling
of the flesh which occasionally occurs in paralytic limbs. The genus
will also extend to two other species;  as the gangrene which com-
mences in a bone and is  usually called a caries; and that peculiar
form qf 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:

   1.  OANGRiENA SPHACELUS.         MORTIFICATION.
  2.  ——------- USTILAGINEA.        MILDEW MORTIFICATION.
  3.      ■       NECROSIS.           DRY GANGRENE.
  4.  " » ------» CARIES.             CARIES.
                        SPECIES I.

             GANGR^NA SPHACELUS.

                       3&ortificatfon.

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

Mortification is a disease of debility; it  is a total torpitude  or
insensibility 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
living power, acquire an ascendency,  a play  of chemical  affinities
takes place, and  putrefaction, or  a  decomposition of the organized
substance, 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: 
GE. XI.—SP. I.]     SANGUINEOUS FUNCTION.
605
      x Inductus.                Superinduced Mortification.
      0 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
Wimringham 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 in-
jury, in a person of florid and vigorous health,  and in the prime of
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 excited
beyond  their strength; they are hence  worn out by the impetuosity
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, liltle 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 symytoms,  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
discharges 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 atmo-
 sphere, 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 palbebrae destroyed in this manner, as if in a
 series of concentric circles.  Even upon surfaces barely contiguous,
 as  the fingers and toes, it generally spreads in a similar way ; so that
* Comment, de morbus quibusdam, &c. No. 54; 
606
HiEMATICA.
[CL. IE.—OR. IV.
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 adjoining
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 a 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 arttry 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 ihe 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 barely
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
varieties, 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
• Principles of Military Surgery, 2d Edit. 8vo. Edinb. 1810. 
QE. XL—SP. 1.3     SANGUINEOUS FUNCTION.
6or
venesection, purging,  and relaxants, while the local applications
should consist of refrigerant epithtms till the entonic action is com-
pletely reduced: after wbich,  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  live 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 external
air.  When a limb in  this state is suddenly brought before the fire,
it becomes gangrenous  almost instantly;  for tjy this means putre-
faction 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 inio 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 degrees,
we shall have  the  best chance of recovering it  to life: since we
hereby afford an opportunity for the warm  and  circulating blood and
 the active principle of irritability  to push  forward  once more into
 the vessels of the frozen structure, which, however, weakened and
 insentient, have not yet become  decomposed, and  to reanimate  it
 with vital power.
   The advantage of plunging a  frozen limb, first into ice-water,
 and  afterwards into water raised just above the freezing point, and
 in this manner  advancing it gradually to a common temperature, is
 of general notoriety;  and it is this plan which  forms the usual
 treatment.  In what w.iy the  benefit is accomplished,  has been a
 frequent subject of  inquiry; the remarks just  offered, may  perhaps
 afford a satisfactory explanation of the subject. 
608
HJEMAT1CA.
[CL. HI.—OR. IV.
                       SPECIES II.

            CANGRjENA  USTILAGINEA.

                  iHa&cto=Ptorttft'catfott.

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

This 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 u ustilago,"
" 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 thfi
spur of a cock, in Latin  clavus, which is the name borne  by  this
parasitic  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 ardens
from the  burning internal heat which is felt in either case. The one
of these  disorders is a typhous fever, with the general character of
pestis, or what Sauvages calls erysipelas pestilens,  which is synony-
mous 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 rapidly 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.  <k Beginning," says  he, "at  the extre-
mity of one or more of ihe 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-
tion, to that  from  external cold, from ligature or bandage ; or to
that which  proceeds  from any known or visible cause, and this as
  • Morgagni, De Caus. et Sed. Morb. Ep. LV. Art. XXIV, Bresl. Sammlung.
1724.1, p. 643. 
GE. XI.—SP. IL]     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 whole
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 I may say that I have seen it  in at  least twenty
males.  I think, also, that I have much more often found it 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 accompanied by apparent distemperature either
of the part or of the  habit.
  In  its severer attacks, however, the constitution seems to be
generally contaminated, the mind and  body become equally de-
bilitated, there is  great irritability, and a tendency to convulsive
action.
  According to  every statement, this  singular disease  seems to be
connected with a diseased state of the  digestive organs, from excess
of living, 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,  than from any morbid
condition of the circulating system, whether atonic or entonic.  And,
hence, we find it best relieved by free doses of opium, in conjunc-
tion  with a generous and  even stimulant diet.  Bark is of no avail,
and  the  local use of spiritous fomentations and cataplasms, warm
pungent 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 confined  himself to the use of  opium alone, of which he some-
times 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 dis-
eased bone dropped  spontaneously  from the affected joint,  healthy
granulations succeeded, and in due time a cure has been effected.

               • Home, Facts, and Experiments, p. 81.
                 Ludwig, Adyersar. I. i. 1. 7. p. 188.
Vol. II.—4 II 
610
MJEMATICA.
[CL. UI.—OR. IV.
                       SPECIES III.

              GANGRiENA NECROSIS.

                       ©rg ©rauflreue.

     THE DEAD PART DRY, 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 whicn, as in
the atrophy of the body at large, the animal oil, flesh, and fluids,
also, 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
being 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 lo ihe limb a purple  or variegated dve.
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.
C Discolor.           The natural  colour changed  to a 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.  Perhaps
the following remarks may afford some clue to this singular ex-
ception.
  We have already  had occasion to observe, under the first species,
that a frost-bitten limb  does not putrefy so long as  it continues
frozen, because the accessaries or co-operative powers of putrefac-
tion, 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, com-
pletely emptied  of its fluids, and  impervious to  atmospheric in-
fluence: and  consequently  there are  the same obstructions  to
putrefaction in dry gangrene, as in a limb killed by the bitine nower
of frost.                                               ° v
   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.III.]    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 it 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
variety of this species, in a man of seventy-two years of 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 all  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

    • Matthzi Francisci Ahx. Med. et  Chir. Doct &c. Observata Chirurgica,
 Fasciculus I. 8vo. Altenburg, 1778. 
612
HJfcMATlCA.
[CL. 111.—OR. IV.
persevering friction, are sometimes found useful in the commence-
ment  of this  disease.   Repeated blisterings and setons  have also
proved serviceable, anil 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.

                           Partes.

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

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
rnD " to 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,f and
Monro,| 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 gene-
ral and pathological, and as summary as possible.
• Surgery, Book H. Ch. 7.
f Maladies des Os. torn. II. Ch. 16.
* Edin. Mid. Vol. V. p. 279. 
GE. XL—SP. IV.]     SANGUINEOUS FUNCTION.              615

  Most of the cases 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 scrofula.
  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 ift the
part affected; tenderness to the  touch; a loose and  flabbf feel of
the superincumbent integuments, and a discoloration  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 vermouille of M.
Petit,  the cells being filled with  a corrupt sanies or spongy carun-
cles, so that the whole assumes a quaggy appearance; and  sometimes
dry and wasted :  and the dry variety,  as in  necrosis,  is  sometimes
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 super-
ficial, 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
separation and removal 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 the dead
 bone  itself.   Celsus  gives a  detailed  account of this  operation,
 which, when the caries was deep, was accompanied with numerous
 perforations 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 off 
614
HiEMATICA.
[CL. III.—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. Several 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 Mumfries, informs us, being sepa-
rated 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, continued  well  afterwards, and
was fit for any country work; the  legs being straight,  with  only a
little  thickness at the ankles. Justamond gives a similar case of the
humerus, and  Sherman of the thighbone.  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 laminae, 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 success-
fully 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
general softness or flexibility of the bones, as in parostia^.rtfis, or
cyrtosis.
   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 various
instances the loss of  substance  was greater in  the  former,  and in
others in the latter.§
* Bartholin. Art. Hafn. Obs. 1.
 Nicholai, Diss. Observ. quxdam Medico-chir. Jen. 1786
f Vol. 1. p. 192-4.  Vol. V. p. 370.
* Vol. III.p. 27.
s Observations on Diseases of the Joints, 
GE. XII.]           SANGUINEOUS FUNCTION.              615


                      GENUS XII.

                          ULCUS.



A PURULENT OR ICHOROUS SORE, PRODUCED  BY THE SEPARATION
                       OF A DEAD PART.
This genus of diseases is, in  every species, a subject of manual
attention,  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
ot nosology founded on a physiological basis.  Ulcus is,  strictly
speaking, a Greek term, with a mere change of one convertible vowel
for another, to give it  more of a Latin form ; the derivative noun
being tXxoi, probably, as conjectured by Eustathius, from fA*«, "tra-
ho," in the sense of " distraho," hereby producing what the Greeks
called a Xvo-it wnxuxs,  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 focal disease ;
sometimes as recent or chronic; and sometimes as mild  or malig-
nant; but, as local ulcers may become constitutional, the consti-
tutional may  assume various forms, the recent be rendered chronic,
and ihe mild and malignant change places, none of these characters
are calculated for clear or permanent distinction.   And hence ano-
ther principle has been appealed to in the volume of Nosology, de-
rived from the variety of their external form, and they have been
contemplated under the following species :
   1. ULCUS INCARNANS.           SIMPLE HEALING ULCER.
   2. ------ VITIOSUM.            DEPRAVED ULCER.
   3. ------- SINUOSUM.            SINUOUS ULCER.
   4. ------- TUBERCULOSUM.       WARTY EXCRESCENT ULCER.
   5. .------ CARIOSUM.            CARIOUS  ULCER.
                        SPECIES I.

                 ULCUS INCARNANS.

                  Stmplr healing aaicer.
THE DISCHARGE PURULENT,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
HEMATIC A.
[cl. in.—on. iv.
 lost by external violence, or some  internal morbid  action, and to
 endow 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 process of incarnation and cicatrization, which
'we have already explained under the genus apostema, will proceed
 spontaneously, and without  obstruction, and  a cure be speedily
 completed.
                        SPECIES  II.

                  ULCUS  VITIOSUM.

                     73r4)rauTur SElcer.

           WITH A VITIATED SURFACE AND SECRETION.

This degenerate condition exhibits itself under various forms, and
results from  various  causes.  The modifications most worthy of
notice are the following:
* Callosum.               The edges indurated and retracted.
  Callous ulcer.
£ Spongiosum.             With fungous or spongy excrescences.
  Fungous ulcer.
y Cancrosum.             With a hard, livid,  lancinating irregu-
  Cancerous ulcer.           lar, and frequently bleeding tumour
                            at its base.
  The causes in each of these may be constitutional or local; and,
in managing the ulcer, it is of great importance to determine  this
point;  for the patient may otherwise be put very needlessly upon  a
long course of alterants, or may omit such a course when absolutely
necessary. If there  be a cancerous, a scrofulous, 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
secretion of pus. And hence if the system be without this condition, 
GE. X1L—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 aciimonious 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 textuie, show a weak and morbid sensibility,
and bleed and die away almost as soon as they are formed.
   Where this is the case, the ulcer, whatever modification it assumes,
can be brought into a  healing train only by increasing  the health
and vigour of the constitution.  This, however, it is often difficult
to accomplish; for, in very numerous instances of obstinate ulcers,
we find the  constitution has been exhausted and worn out by hard
labour, hard drinking, or a long exposure to a  tropical sun, and is
labouring  under a  long train of dyspeptic, hepatic,  or podagral
symptoms.   It is not necessary to repeat the plan it will be incum-
bent  upon us to  pursue under  these  circumstances, as 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 1 educed 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 pioductive 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 ot 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 a rapid execution he heats
 several of these at ihe same time in a fierce fire, and uses them at
 a white heat, passing each in succession with great speed oyer  the
 morbid part, so as to make a considerable rut  or groove as he pro-
 ceeds. The pain endured seems to be far less than might be expected.
   Vol. II.—4 I 
618
ILEMATICA.
[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 scirrhosities about the lips, and other parts of  the surface.
 And it is peculiarly calculated for radically destroying many of those
 irregular and spongy excrescences which, from their  readiness to
 bleed freely, have been distinguished by the name of fungus hama-
 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 lime 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 restraint,
 and there is great difficulty in destroying it without  destroying the
 organ from which it issues.  But wherever the band can follow them
 they are often repressed, and have been sometimes extirpated  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.

                      Sfnuous Juicer.
 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 
GE. XII.—SP. UI.]   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 uiethra.
  These sinust s 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; und 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 recourse
to where  it is deeper; and attempted first  by irritant and even erosive
injections, so as to excite a new inflammation down the whole  course
of the canal; and afterwards by pressure applied at first to its  lowest
part, and advanced gradually to its mouth; or, which is better, by a
seton passed from the orifice of the ulcer lo 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 fiom the vicinity of large blood-vessels
or nerves, it is by far the speediest and  most  decisive of the  whole.
                       SPECIES IV.

              ULCUS TUBERCULOSUM.

                SEfartg Excrescent ©Uccr.
 WITH TUBERCULOUS  EXCRESCENCES,  LOBED BY RAGGED  ANE
                   SPREADING ULCERATIONS.
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 
620
HJEMATICA.           [CL.1II.—OR. IV.
come in  contact with it;  and the ravenous, or wolf-like voracity
with which it preys on the neighbouring organs, spreading in rag-
ged and  fungous  lobes, or with cracking and callous edges, and
destroying the skin through an extensive range, and the muscles to
a considerable depth.
  A valuable practical  paper upon this disease is to  be  found  in
the Philosophical Transactions,* addressed to the Royal Society by
M. Daviel, surgeon to Louis XV. of France; who describes it as a
cancer, to which, indeed, from its tendency to ramify, and the viru-
lence of its discharge,it has some resemblance; and whence Sauvages
denominates it cancer Lupus. It commences in the subjacent peri-
osteum or perichondrium from a diseased  condition of the organ;
at first assumes externally the form of a tubercle  or wart; and
though found over the body generally, is most common to the eye-
lids, nostrils, cheeks, and other parts of  the face.  It  is highly irri-
table; and when the tubercle  has acquired the size of a fig or a
filbert, it ulcerates the cuticle, shows a callous edge,  and spreads
with a most offensive ichor in  every direction : often throwing forth
fungous excrescences from the bottom.
  Occasionally before it opens externally, from the acrimony secreted
below, an herpetic  vesication is formed on the surlace.
  If partially extirpated, it grows again with rapidity and to a greater
extent; caustics always exacerbate it; and the only radical cure con-
sists in dissecting the diseased part, and removing the whole of the
periosteous or cartilaginous base as far as it appears to be affected.



                        SPECIES V.

                  ULCUS  CARIOSUM.

                      <£artou$ ©Hcer.

IHE 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. XL1X, year 1755.
  END OF VOL. IF. 
 
 
 
 
 
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