Book Reviews

Genetic manipulation: Impact on man and society.Werner Arber, Karl Illmensee, W. James Peacock and Peter Starlinger (eds). Cambridge University Press. 1984. Pp. xiii + 250. Price £17.50, $35.00 (US).

It is the foJe intention of the author to prove by arguments and fa<??s, the inefficycy of the dodtrines taught by Dr. Darwin and Dr. Ilaighton, on the myfterious fabled of animal impregnation;" and not thofe two phyfiologifts only, but " all who give exclufively to one fex the power of reprodu&ion.
" In tracing the procefs of generation," fays Mr. P. " theories have ranged themfelves on three diilinf* grounds, each of which haSihad its ardent advocates, and as ftrenuous opponents. One gives to woman alone the humble office of affording a proper nidus for the due evolution of the fostus, which according to this theory already exifts in the male ferr.en, and requires only a fruitful habitation. Another directly reverfes this pofition; it puts the female in pofieffion of every requifite for the formation of a new animal, and confiders the male a mere Simulating engine to call the latent powers of the female into life. The third gives not pre-eminence to either fex, but with the mutual embrace produces a mutual effeft; it regards both the male and female as mod efientially concurring in the work of reproduction, each affording a femething, which, uniting under proper circumftances, becomes the proximate caufe of impregnation. *' Although every exilting theory on the reprodu&ion of animals is reducible in its principle to one of the above grounds, the warm and fertile imagination of fpeculative minds has led to almoft innumerable modifications, each theoiift afiuming his fundamental pofition, and forming his deductions in manner and refpeft to the direction of his fancy." After combating the opinion that corpora lute a 'are decifive proofs of impregnation, he fays, " What a train of evidence, embracing fa&s moft pofitive and indifputable, does that author call up againft him, who maintains that the male femen alone poffeffes the power of ftimulating the os uteri and adjoining parts, and that by fympathy generation is-effected. When a negro man embraces a \yhite woman, why is it that the offspring is a mulatto ? When a male afs copulates with a mare, why does the mule partake of the nature 25S <*iature of both ? And when dogs and bitches of different fpecies have intercourfe, why in appearance do the mongrel whelps claim affinity to both parents? Again, it is a felf-evideut truth that a child may inherit the difp.oiition to the conlikutional difeafes of cither parent; and (hall it be laid, that it is in. the power of sympathy to hand down to pofterity the contaminated habit of the father ? Befides, if the femen, be allotted merely to fUmulate the uterine fyltem, it would feem a totally unueccflary-fecretion; toJf we find that the fexual aft is not wanting, even to. effect thofc changes, which the femen, by this theory, is only permitted to perform." Treatise 011 Febrile TXiseases, including Intermitting, Remitting? and Continued Fevers ; Eruptive Fevers, Inflammations-, Hamorr-kagies, and the Frnfluvia ; in vohicb an Attetnpt is made to present, at one Vievj, vcbattver, in the present Sate of Medicine, it is requisite for the Fhvsician to kno-jj respecting the Symptoms, Causes, and Cure of those Diseases. Bv A. P. Wilson, M. D. F. R.S.' Ed. Fellow of. the Royal College of Phyficians, Edinburgh, &c.
Vol. II. 8vo. pp. 580. Winchefter, 1800. London, Cad-ell: and Davies, Callow, &c. Our readers will fee our account of the Firft Volume in thefecond vol. of the Med. Journal, p. 390. That volume having exhaufted iatermittents and continued fevers, Dr. W. postpones the Phlegnwfia of Dr. Cullen, and in this fepond volume completes his First Part, or Idiopathic Fevers, with the J$x#nthq?iata.
In the preface to this fecond volume, Dr. W. replies to feme criticifms on tiie fu ft, anl, as we predicted, his observations on the Brunonian fyftem and nofology have not elcaped notice.
He replies, " The Brunonian doctrines have be-n fo warmly contelled, and fo frequently miftated, that I examined them with a degree of caution and mjnutenels, which wouid not otherwife have been neceffary. And aware as I was of the hypothetical manner in which the proximate caufe of fever had been treated by every other writer as well as Dr. Brown, it will be admitted, I hope, that 1 have not departed from a dtje degree of caution ia any of my observations on this fubjett. " With all the care I was capable of, however, I have not fucceeded in conveying the fame ideas to every reader. It has been ftated by on^, that I efpoufe the,general principles of ihe. Brunonian fyltem; by another, that I "admit no part of it b,ut that which was admitted' by all phyiicians, before Dr. Brown's Ele? mcnts of Medicine appeared. By one, many of my objections to this fyitem are regarded as? invalid; by another, their validity i< admitted, and I am cenlured for allowing it any merit at all. I am laid by one to aim at extending the Brunonian fyitem; by another, accufed of attempting to bring about a coalition between s the fyftems of Dr. Cullen and Dr. Brown, which the critic more juflly than elegantly obferves, is as hopelefs a talk as endeavour kaS 25? _Z)r. Wilson^ on Febrile Diseases! ing to milk he-goats. What fhall I fay in anfwer to fuch contradictory 'objections ? I fhall only obferve of the two laft, that I am perfe?tly unconfcious of having made either the one attempt or the other. All I have attempted is to give an accurate view of the Brunonian fyftem, to feparate the true from the falfe parts of it, and to arrange certain fadls relating to the laws of excitability ?without reference to any fyftem whatever. I fhall here endeavour in a few words to place the refult of what was faid of the proxi* mate caufe of fever in a clearer point of view. ,s When a ftate of exceffive excitement or atony exifts independently of the continued application of fome artificial agent, one of two changes muft have taken place; either the quantity or quality of the natural agents, or the ftate of the living folid, is different from that which prevails in health. If it can -be fhown that the ftate of the living folid remains the fame, it follows that the deviation from heajth is owing to fome change in the natural agents ; if it can be proved that the ftate of thefe agents remains the fame, it thfen follows, that the deviation from health is owing -to fome change in the ftate of the living folid. We nry go a liep farther ; if it can be proved that fome of the natural agents rer4?in unchanged, and yet produce effe&s different from thofe they produce in health, it not only follows that the ftate of the living folid is changed, but alfo that, if this change in the ftate of the living folid will account for the changes obferved in the effects of other natural agents, we are not in any degree to attribute fuch eftedts to a fuppofed change in thefe agents, there being no occafion for any fuch hypothefis to explain the phenomena. In fever, many of the natural agents, caloric, food, light, noife, for example, evidently remain unchanged, the difference in their effetts, therefore, is owing to a change in the ftate of the living .folid. But thi*s change is capable of accounting for the change we obferve in the effefts of thofe agents whofe condition we cannot with precifion afcertain, the circulating and other fluids. It follows, therefore, that whatever change may take place in thefe during the progrefs of fever, and however this change may modify the fymptoms of fever, too great lentor, acrimony, or other morbid condition of the fluids, is not the proximate caufe .of fever.
With refpecl to the hypothefis of fever depending on a change in the ftate of the fimple folid. As the natural agents aft not on the fimple but on the living folid, it is neceflary to fuppofe a change in the ftate of the latter ; and as this change accounts for the phenomena of fever, there is no occafion for any other fuppofition.
tf And farther, as all the natural agents excite a morbid aftion, and as this effett is not confined to any one, but obferved equally in every part of the fyftem, what room is there for fuppofing that any one part is more particularly aftefted than every other ? " Laftly, with regard to fever being a ftate of accumulated or exhaufted excitability, in the fenfe in which Dr. Brown ufes thef? terms* Dr. Wilson, on Febrile Diseases, terms, it is only neceflary to refer to the fa&s, which prove tha$ no fuch morbid ftates exift. Itis true that the phenomena of fynocha are fuch as we fhould expeft from an accumulation of excitability ; but will a furfeit, or 'an exceffive quantity of diftilled fpirits, frequent caufes of fynocha, occafion an accumulation of excitability? ft appears then, that in fever the living folid is fo changed, that a Change is effected in the laws of its excitability, and that this admitted, there is no occafion for any of the foregoing hypothefes to explain the phenomena eftential to fever. Upon the whole then, the following, as far as it goes, would ap-r pear to be a juft view of the nature of fever. ,25S ? Dr. JVilsan, on Febrile Diseases? bours of the nofologift, recolledt that it is his province to pom? out the fymptoms which ditlinguiih one difeafe from another, and to arrange difeafes in fuch a way as may be it lhew their affinity, and consequently aflift the memory in recoilc&ing their modes of treatment. The anatomic detects the changes induced by internal difeafe; but of what ufe would this knowledge prove, did not the nofologift point out the means of afcertaining the prefcnce of fuch morbid Hates previous to death. In vain might the chen.ifE and botanift fupplv us with medicines, did not the nofologift enable us to diftinguifh the cafes in which they are ufeful. " It has been aflerted, that the praftice of medicine would be improved by attending to fymptoms individually, without attempting to afcertain their various combinations, and applying to thefe combinations particular names. Thofe who make this aflertioi\ maintain, and if the affertion is true, juftly maintain* that nolology is an pfelefs leudy. Is the allcrtio:; true ? Does any fymptom at ali times require rhe fame mode of treatment? Nay, is not the fame fymptom in one cafe falutary, in another pernicious? We mull, therefore, be influenced in treating each fympton'i by an attention to tiiofc which accompany it, that is, an attention to the combinations of fymptoms is necefary, and confequently nofalogy of the ftrit importance. By far the greater number of miltakes I have witneffed" in practice, have originated from the neglect: of nofojogy. It often happens that an opinion, at firft maintained on no other account than its Angularity, becomes current among thole who are unable, or will not be at the trouble, to think for themfejve.s. Many exclaim again# nofology, but cannot tell why. The truth is, an accurate knowledge of it is acquired with difficulty, and the indolent are glad of an ^pplogy for neglefiting k altogether.5' He concludes his preface thus: ??< Contrary to*my firlt intention, the prefent volume includej all the fpecies of eruptive fevers, and confequently finilhes tliQ tirft part of the work, comprehending idiopathic fevers. The two volumes now publilhed, therefore, form a Treatife on Idiopathic Fevers, and may be regarded as independent of thofe which ?re to follow. " The Symptomatic Fevers will form the three remaining volumes. in the firlt of which, that is, the third volume of the work, ifch? inflammations of the tkin, head, and neck, will be conlldered; jtt the fourth, thofe of the thoracic and abdominal viicera, and ?f the joint?. The laft vqlume will comprehend the hemorrhages and proftuvia, with a more detailed view of the nofology of LrKedifeafc.^ .: . .
A; our readers have probably more curiofity re fpefliiig the Plague tftan either of the other difeafes treated of in this volume, We fnall prefeut them with a few extracts on that iubj.ct: " Of the Plaguetc Although few Britiffi phyficians have occafion to praflice in the plague, the propriety of being acquainted with a difeafe, which has demanded fo much attention, and bear-, fo llrong an analogy to complaints which every day fall under their care, is too apparent to require any comment. Befules, we cannot forefee in what circumftances we may be placed; and for a phyfician to betray ignorance of the plague would be unpardonable.
" There are few difeafes fo remarkably varied, and there are few, perhaps none, of which it is more difficult to give an account, which fhall be at the fame time fufficiently full and diftinfl. The reader will find the beft writers, who have had an opportunity of feeing the difeafe, complaining of this difficulty. " As much as poflible to prevent confulion, they have divided the plague into different claffes; nor is it poffible without this to give a juft view of the complaint, finee' no two difeafes are more oppolite than the different forms of the plague, in one we fhall End it the moll dreadful of all fevers, deftroying without exception' all whom it attacks ; in another we fhall find it confuting chiefly of an eruption unattended by danger. Why, it may be laid, are difeafes fo different, regarded only as varieties of the fame ? However different thefe extremes, they are not only produced by the fame fpecific contagion, but almoft infenfibly run into each Oiher; from which we may form fome idea of the variety which the , plague prefents. It will not then appear furpriling that the difficulty of arranging its fymptoms, fo as on the one hand to avoid confufton, and on the other to give a compreheniive view of the complaint, be very great. In fact, there is no author, although moil of thofe who have written on the plague fpeak from their own obfervation, who has overcome this difficulty, lit all, we find the account either fhort, and confeijuenily more or lefs imperfeft, or of eonfiderable length, and more or lefs con fa fed. So varied are the fyptoms of the plague, that if the common varieties are given, the account muit be tedious, and then it is impoifible perhaps to pievent it being in fome degree p rplrxed. " I fhall not fpend time by laying before the reader the modes of divifion adopted by different writers, or by pointing out the objections which might be made to thein. The objections conftii chiefly, in many of the divifjons not being marked with fufficieqt precilion, fo that it is often impoffible to lay what are the correfponding divifions in the different accounts of the difeafe; as the reader will perceive if, for example,-hecornpire together the different accounts of the plague in the Traise de la Peite, or any of Lis thefe Dr. mlson, on Febrile Diseases'* thefe with the divifion adopted by Dr. Ruflell, in his. Treatife oil the difeafe.
" In dividing a difeafe into varieties, each variety muft be marked by fome fymptom which constantly attends it. It muft not be accidental or unconne&ed with the ftate of the fymptoms in general, which would render the divifion ufelefs; but muft mark a variety, in which the fymptoms on the whole, and, what renders the divifion of more importance, the prognofis, difrer from thofe of ?other forms of the complaint. " I lhail not defer a particular account of the eruptions, namely, the buboes, carbuncles, &c. till after the different forms of the dileafe have been confidered, as has ufually been done ; by which we are Forced to ufe terms before they have been defined ; nor on the other hand, is it proper, where the variety is fo great, to interrupt the account of the general courfe of the difieafe, in order to defcribe the different eruptions. It therefore appears neceffary to depart from the ordfer which has been purfued in laying down the fymptoms of the other exanthemata, and to regard bubo, carbuncle, See.
as terms which muft be defined, before proceeding to give the fymptoms of the plague. " Of Pejiilential Eruptions< " t. Of pestilential Buboes.
" A peftilential bubo at its commencement is a fmall, hard, round tumour, readily perceptible to the touch, about the fize and fhape of a pea, it is moveable under the iTcin, the appearance of which is not altered at an early period, the bubo lying at a greater or lefs depth, and the fwelling not appearing externally. <e As the tumefied gland enlarges, it changes from a found to an oval fhape, becoming at the fame time lefs moveable. The integuments now begin to thicken, and the fwelling to appear externally. " The appearance of the bubo is often preceded by a fenfe of tightnefs and pain fometimes lancinating, or itchinefs, in the part where it is about to appear, now and then by fliivering. In many cafes, however, the fmall fwelling juft defcribed comes on without being preceded by any peculiar fymptoms. " Some buboes are indolent and infenfible, others Very fenfible and rapid in their progrefs. The tumour advancing quickly to fuppuration, is generally regarded as favorable. When the buboes fuppurate properly, De Mertens obferves, and there is a feparation of efchars from the carbuncles, with a remiffion of the febrile fymptoms, the prognofis is good. No general rule however can be laid down. Cafes where early fuppuration takes place often prove fatal; and there are many hiftories of cafes terminating favorably where the buboes were extremely indolent and terminated in refolution. " It is difficult to forefee in what way a bubo will terminate. has been very evident, Their progrefs indeed is almofl always more or lefs irregular, efpecially after the firft week.; At one time they feem advancing to Suppuration, at another (how a tendency to ' rcfolution. ' But thefe variations,' Dr. RufTell remarks, ' chiefljr c refpefted the integuments ; for the gland itfelf when carefully ' explored was feldom found to alter, and where the tumour ac-* tually difperfed, it was not fuddenly, but by flow degrees* Thus * from the alteration in the teguments alone, the whole tumour, on * a Superficial view, feemed to leflen or increafe, though the gland * remained the fame; and I am inclined to think that this deception * was often the caufe of the bubo being faid to flu&uate, or to * vanifh in appearance entirely, and again return.' He adds, however, r At the fame time I am far from thinking that this fluclua-* tion was never real.' And Chenot obferves, ' Vidimus quoque * abruptam fuppurationem in his refufcitari ac demum per eifufioe nem puris abfolvi.' " The bubo as it increafes in fize becomes fomewhat flat; and generally about the fecond week the (kin over it grows tenfe and painful, and begins to be inflamed. In fome cafes the inflammation is moderate* in others confid<?rable ; but it feldom terminates in gangrene, although the (kin now and then ailuines a bluifli colour. " It fometimes happens/ however, that the bubo runs to fuppuration without any degree of inflammation appearing on the fkin, and then, as it is generally harder than a fuppurated venereal bubo, it is often difficult to determine whether fuppuration has taken place or not.
When buboes break fpontaneoufly it generally happens in the third week, fometimes at a later period.

"
The buboes moft frequently appear in the groins or a little lower, among the loweft clufter of the inguinal glands; they alfo frequently appear among the axillary glands; fometimes, though, more rarely, they have their feat in the parotid, and the difeafe is then by many reckoned more dangerous than when the buboes appear in the groins or arm-pits. Still more rarely they appear in the maxillary or cervical glands. ' The latter too,' namely, the maxillary and cervical glands, Dr.
Ruflell remarks, ' were feldom obferved to fwell without either the ' parotid fwelling at the fame time or foon after, or a carbuncle pro-* truding near them; they never were the fole peftilendal eruptions* * and I recoiled few inftances of their coming to maturation.' It has been remarked by others, that the parotid bubo feldom appears unaccompanied by one or more in the axilla or groin. " It may upon the whole be obferved, that the axillary buboes fuppurate more frequently than thofe fituated about the fauces, and the inguinal more frequently than the axillary. " Buboes often make their appearance on the firft day of the complaint; fometimes indeed they are among the firit fymptoms.
It has been obferved, that when they appear later than the third or fourth day, they are generally preceded by an exacerbation of the febrile fymptoms. Thofe which ccme out at fo late a period, however* ?62 Dr. iPtlsM) on Febrile Diseases'. however, iire not, for the molt part, the firft which appear in the' fconrfe of the complaint: for a fucceffion of buboes fometimes takes J?!ace, tiil three or four have made their appearance. In this cafe feveral hours ufually intervene between the appearance of any tw$ of them. " It fomctimfo happens that no buboes appear, and thefe cafes are upon the whole the moft fatal. This is a circumftance which, particularly dem W.ds attention, as the cafes unattended by buboes and otheh peftilential eruptions generally make their appearance at the commencement of the epidemic, and have often, in confequence of the abfcrice of the eruptions, been miftaken for other complaints. In other cafriS, particularly towards the decline of the epidemic, the buboes and other eruptions often form the principal part of the Complaint, which is then unattended by danger; from which it would appear, that the eruptions in the plague are to be regarded as favorable fymptoms; but of this 1 fhall prefently have occafion to fpeate more particularly.

"
Where tiie inflamed, gland advances to fuppuration more rapidly than the integuments, troublefome fiftulous ulcers are fometimes formed,, if an artificial opening has not been made in the fkin. tV.is accident however is rare; in general the buboes, left to themfelves, do not prove troublefome. ??
When they do not fuppurate, and the patient recovers, they gradually dilperfe, generally in the fpace of a few Weeks. In fome cafes they are fucceeded by an induration of the glaiid, which remains for many months.
Even where fuppuration has taken place, if the cure proves tedious, either in confequence of the matter having been discharged by too fmall an opening, or the opening having repeatedly c'ofed in the progrefs of the cure, a fimilaf induration fometimes fuccceds, which in like manner fooner Or later difappears, thefe indurations never terminating in cancer.
? Such are the circumftances to be learned from attending to the external appearances of the buboes; fome further circumftances, of Iels moment however, have been afcertained by dilTection. " It has been the pra&ice of many, particularly the French furgeons, to extirpate the buboes, which gave them an opportunity of obferving the internal changes which take place in them. ?
From the appearances on diifettion they have been divided into feveral diiferent fpecies. It is unnecefTary to detain the reader with an account of this hitherto ufelefs divifion; he will find it at length in the Traite de la Pefte from the 428th to the 434th page. One observation deferves attention ; it has juft been remarked, that the fkin covering the buboes never runs to gangrene; difledtion lhows that it is othervvife with refpt-cl to the gland itfelf, 4 Je coupai p.ir ie milieu celle (h. e. the bubo) qpi etoit fur les ' vaiffeaux, que je trouvai toute noire. Lc lendemain j'ouvris ie * bubon, j'y trouvai le corps glanduleux comme un rein de mouton, e tout noir.' " Befides the true bubo, another peflilential eruption has alio receivcu the name of bubo. This eruption is fo rare that fome who Dr. JVlhon, on Fehrlk Diseases.
"who mention if have been rccufed of mifreprefentation. This accufation vve are now aflured is groundlefs. " The principal "circumftance in which the fpurious differs from the true bubo, is in the former appearing indifcriminately on a'moft every part of the body, while the true bubo is confined to the groin, axilla, and par^s about the fauces. ' Spurious buboes ' were obfefvedfavs Dr. Ruffell, * on the head, the forehead, 1 the throat, the fhoulder, above the clavicle, the neck, on or * above the fcapula:, the back, the fide under the hrcaft, the belly, * the hip, hind part of the thigh near the ham, the leg, the * fcrotum, the arm near the ufual place of iifues, in fide of the arm 4 near the elbow, outfide o* the fore arm, and near the wrift.' " Some of thefe buboes, if they are not lanced at a proper time, grow to a great uze, particularly thofe on the fcapula: or back ; in other parts, however, they feldom much exceed the fize of a common hen's egg. They generally m ke their appearance about the fecond or third day, and for the moll part after the protrufion of true buboes or carbuncles. They generally fuppuiate, though, lefs rapidly than the true buboes.
-* " Next to baboes, carbuncles are the molt remarkable of the pcftiiential eruptions,, " The reader will .find carbuncles divided by different writers into feveral varieties.
One makes three, another lour, a third five different kinds. " Dr. Rullejl divides the carbuncles he met with, into live varieties. " The firft appeared in the form of a fmall puftule about the fize of half a pea, on its upper furface of a dulky or yellow colour, and a little wrinkled, The fkin which immediately furroumied this puftule was hard and inflamed. The puftule itfelf fuon became very painful, and continued to increafe till it became a tumour of the fize of a nutmeg, and fometimes that of a walnut, and a yejlowifh matter was felted under the cuticle, which was fomfctimes moift, at other times dry and crufty ; the reil of the tumour affumed a dark reddifh colour, the circle which furrounded it appearing at different times of various hues. '? On the third, fourth, or fifth day of the carbuncle, a gangrenous cruft appeared on the middle of it, which foon occupied the whole furface of the tumour, exactly refembling the blapk. efchar formed by cauftic. " This cruft, when the termination was favorable, was thrown off by fuppuration, leaving an ulcer of various depth, which for fome time continued to difcharge matter. When the cafe terminated fatally, the cruft remained dry and often fpread to the inflamed circle, furrounding the carbuncle, fo as to form a gangrene pf confiderable extent. " The fecond kind ofcarbuncle appeared in the form of a fmall angry puftule, not riling fo high as the former, more difpofed to fpread, and becoming gangrenous on the fecond day. Iq this ft^te it 264 Dr. Wilson, on Fehrile Diseases, it was not eafily diftinguiihed from the other, but was generally furrounded with a more highly inflamed ring. It chiefly attacked tendinous parts, particularly the joints of the fingers and toes. " In the third variety, the cuticle was at once raifed into a blifter of the fize of a horfe bean, filled with a dufky yellow or blackifh fluid, and the fkin which furrounded this variety of the carbuncle was lefs tenfe and of a paler red than that furrounding either of the foregoing. When the bliller broke, the cuticle fell upon the flat furface, which was of a dark colour and foon became black. At this period, that is, about the third or fourth day of the carbuncle, it refembled the preceding varieties, except that it ?was flatter.
The circle furrounding the efchar gradually affumed a very dark red, but never became gangrenous. The efchar was about the fize of a fix-pence. This carbuncle was very painful, and five or fix fometimes appeared on the fame patient. " The fifth and laft variety appeared at firft a puftule, which, on the fecond day, refembled that of the fmall-pox; it roie in the form of a cone to twice the fi?e of a large diftinft pock with a blunt yellowilh point, which, inftead of advancing to fuppuration, became black to the fize of a large field pea. The gangrene in this cafe however did not fpread farther. The margin became of a dulky red, but appeared brighter as the fuppuration. which threw off the efchar advanced. After the fecond day, this differed from the third arid fourth varieties only in the gangrenous part being of lefs extent, and the puftule more raifed. " There are certain eruptions which now and then appear in the plague in fome refpedls differing confiderably from any of the carbuncles juft defcribed; in others refembling them. Such is the eruption which has been termed papulae ardentes, or fire bladders. ** But it would be tedious to enumerate all the various eruptions of this kind which have been obferved in different epidemics.?? The true peftilential carbuncle may be defined, a pultular or veficular eruption, fooner or later running to gangrene. " The eruption called anthrax, is nothing more than a car* buncle after it has become fphacelated.
(< Carbuncles, to whatever variety they belong, for the mo$ part do not exceed the fize of a walnut; they have fometimes been obferved confiderably larger. The time of appearance is uncertain; they fometimes Ihew themfelves on the firft day of the complaint, but more commonly not" till a later period j and when feveral ap-P?a?
Dr. Wilson, on Febrile Diseases'' 26$ pear on the fame perfon, they generally fucceed each other rapidly.
They have been known to come out as late as the eighteenth or twentieth day. " Refpetting the number which appears on the fame patient. Dr. Ruffell obfcrves* ' Of thofe of the firft and fecond fpecies fel-* dnm more than one or two were obferved in the fame fubjeft, in * general one only. The other varieties occurred in greater num-* ber, and including thofe of the fifth, I have fometimes counted * between twenty and thirty, but this happens very rarely.' '? This eruption is always attended with confiderable pain, which in fome cafes is very violent. No external part of the body is exempted from carbuncles. ' I have obferved them every where,* the author juft quoted remarks, ' the penis and fcrotum not ex-< cepted, but never obferved them on the tongue, the tonfils, and ' internal parts of the mouth,' (there have been inftances however of their appearing on the tongue) though in carbuncles on ' the * cheek, near the corner of the mouth, the gangrene fpreads in- ' wards, and in one inftance of a carbuncle on the eye-brow, the * gangrene fpreading upon the globe of the eye had deftroyed part * of it.' " The carbuncle is a lefs favorable eruption than the bubo. Carbuncles were regarded by the Ruffian phyficians, Dr. Guthrie informs us, as a. fign of greater malignity than buboes; but of this prefently. They thought the carbuncle indicated lefs danger when Ted than when livid; when it fuppurated than when it did not.
When the hands and feet were the feat of carbuncles, Dr. Guthrie obferves, the patient feldom or never recovered. Carbuncles on the fpine were alfo regarded as particularly unfavorable." " Of the other Symptoms of the Plague. " That I may abridge the followwg account of the fymptoms ?f the plague, and consequently render it more dittinft, it is proper to obferve, that all the fymptoms both of fynocha and typhus occafionally attend this fever. It is unneceffary again to detail all of thefe, for which I refer the reader to the firft volume ; and fhall hefe confider at length, thofe which charafterife the plague, or appear in this difeafe under peculiar modifications. " It has already been remarked, that in the feveral divifions of the plague adopted by writers, many of the varieties are ill defined. They feem to be marked by accidental fymptoms, and fome of them by no particular fymptom, but by the general mil4nefs or feverity of the difeafe. In the former cafe the divifion can be of no ufe; in the latter it can admit of no precifion. Befides, moft writers on the plague, fpeaking from their own obfervation alone, defcribe the complaint as it appeared in one or two epidemics, and in almoft all epidemics there are peculiarities. It is only by comparing many, that we. can form an account of the difeafe generally applicable.
" On comparing different epidemics, we fhall find, that what, ever be true of other eruptions, buboes are falutary. always mark a form of the diiVafe lefs generally fatal than that unattended by this eruption. < Thofe perifhed,' Dr. Rufleil remarks, ' fometimes within the twenty-four hours, fometim \<= on ' the fecond or third day; they had neither buboes ntor carbuncles, ' and it was very rare to find fufpicious marks of infection on the ? dead bodies.' In another place he obferves, ' the total abfence of buboes in thofe who died fuddenly I have doubt of.' He alfo remarks, * that the plague, under a form of all others the moft ' deftru&ive, exifts without its charadleriftic efuptions or other ex-' ternal marks reckoned peftilential, can admit of no doubt.' The Ruffian phylicians, Dr. Guthrie informs us, found the cafes attended with buboes lefs fatal than thofe attended with carbuncles. Carbuncles and petechia:, De Mertens, in his account of the Plague cf Mofcow, obferves, are not critical eruptions, they only denote a putrid condition of the humours; whence it follow^, that in proportion as buboes are more common, and petechias and carbuncles more rare, the milder is the plague. Orrceu3, in his Treatife on the fame Plague, obierves indeed,, that buboes often attended the moft acute form of the difeafe; yet in another place he informs u?, that there were no buboes in the worft form, their germs only being fometimes obferved after death ; and Samoilowkz, in his ac.ount of this epidemic, in defcribing the worft form of the difeafe, notices petechias and carbuncles as frequent fymptoms, but makes no mention of buboes. weight in the head, confufion of thought, giddinefs, deje&ion, and Op; ;effior> about the prsecordia, often accompanied with a bitter taft? in ?' e mouth. * The patient is inclined to be filent, (hews much an iety in his countenance, but makes few complaints; the febr.le1 fymptoms are very moderate. The attendants luppofe the patient a little indifpofed, but lufp.dt nothing alarming ; yet fuch patients often die within the fiift twenty-four hours, fometimes on the fecond day-" In general, however, this form of the plague makes its attack lefs deceitfully. In an epidemic defcribed by Chenot, that of Marseilles, and many others, the fymptoms from the firit were alarming. the complaint often appearing with violent and irregular ihaking.
" Delirium is fometimes the firft fymptom obferved. At othertime-, a remarkable /late of the pulfe, which very fuddenly becomes fo weak that it can hardly be felt, frequent and inter* mitting, with much debility and languor, introduces the difeafe.. The proftration of ftrength is fometimes fo fudden and complete, that Mr. Smith, Dr. Guthrie informs us, faw men in apparent ?good health, on being infected by the plague, fuddenly drop down as if fhot by a mulket ball. Sometimes, inflead of mere -debility and laffitude, the patient is affected with extreme horror and defpair, and his fpirits fink fo low that nothing can recall them. " At other times, the difeafe attacks with very flight chills, foon followed by a burning heat, which remains during the difeafe ; as foon as the heat commences, the patient complains of infufferable head-ach and exceffive thirft. Sometimes, as in the plague of Ruffia, defcribed by Orrceus, the patient is fuddenly feized with violent ihivering fucceeded by a hot fit, the Havering and hot fit alternating feveral times.
" The firft fymptom of the plague is fometimes a violent beating of the temporal arteries, while the pulfe at the wrift is fmall and feeble.
In this cafe the heat is generally moderate, but the head-ach intolerable. In the plague which raged at Lyons in 1628, a burning heat in fome of the vifcera, and a dull pain, or rather great heavinefs of the head, announced its approach. " The plague fometimes comes on with violent palpitation, and ftrong convulfive tremblings. The plague which raged iix London in 1665, often made its attack in this way, ? " As the complaint advances, it afiumes more of the appear-^ ance of the fevers we have been confidering. The inflammatory fymptoms generally run high for the firft day or two; but for the moft part, the plague aftumes the form of typhus at ferent The hitter tafte in the mouth the reader will find mentioned by difi rent writers as chara&eriftic of the plague. It is obferved by fome, that favourable change feidom happened while this fymptom continued. M in 3 an early period; and the patient foon becomes delirious or comatofe. , : " The delirium is fometimes of the furious kind, particularly, Orrceus obferves, in thofe of a robuft and full habit, and in whom a fijll meal appeared to be the immediate exciting caufe. In ge-r neral, however, the delirium is of that fpecies which chara&erifes typhus^ the patient appearing rather ftupid than outragepus, and complaining of a pain at the heart, a fymptom frequently ohr ferved in the plague. When coma comes on early, it has been looked upon as affording a worfe prognofis than delirium, particularly if it fuffers no evident remiffions during the day time.
Both delirium and coma indeed are almoft always moll confiderable during the night. The remiflion in the day time is generally more evident when the patient is delirious than when he is comatofe. " Whether he-becomes comatofe or not, there is always prefent a very remarkable muddy appearance of the eyes, which is fometimes obfervable at the very commencement, and is one of the moil charadleriftic fymptoms of the difeafe. This appear-' ance of the eyes in fome degree refembles that in the laft ftage of malignant fevers. It is not, however, defcribed as altogether fuch, for with the muddinefs there is blended a degree of luflre.
It is an appearance in fhort very remarkable to thofe who have feen it, .but not eafily cpnveyed in words. " Almoft all writers on the plague take notice of a peculiar jcad of countenance, which to thofe who are converfant with the difeafe, is one of its beft diagnoftics. It was the ftate of the eyes, Dr. RuflHI remarks, which contributed chiefly to occafion that confufion of countenance which he does not attempt to de,.
icribe, but from which, after repeatedly obferving it, he could with fome certainty pronounce whether the difeafe was the plague Or not. " The danger is very generally proportioned to the degree of this fymptom. When the eyes rcfume the natural appearance, particularly when this happens after fweats, the prognofis is favorable. But in the form of the plague we are confidering, this hardly ever happens. In the comatofe the muddinefs of the eyes is moft remarkable. Their fiercenefs is raoft ftriking in thofe who labour under delirium, particularly the furious delirium ; and it fometimes happens, that the coma and delirium, with the peculiar cafts of countenance which accompany them, alternate with each other.
In the delirious, however, there is ftill an appearance of muddinefs, and the eyes retain fome luftre ia the comatofe.1 Thefe appearances of the eyes are lefs remarkable in children than in adults.
Such is the beft account I have been able to colledl from the obfervations of thofe who were converfant with the difeafe, of that peculiar appearance of ;he eyes, which all who have feen thp plague ajree, fo remarkably charafterifes it. " The changes which take place in the eye are not always confined to its appearance only; the rf una fometimes much affetted. The patients . Dr. Wilson, an Febrile Diseases* '2.6$ "patients complain of feeing fparks, flafhes of fire, and various colours palling before the eyes ; this 13 only a greater degree of the fymptoms termed mufcae volitantes. Deceptions of fight, however, are not frequent fymptoms in the plague. Deceptions of hearing are ftill more rare. Deafnefs, as in other fevers, is generally a favourable fymptom, but it feldom attends the plague. With refpeft to the other fenfes, nothing particular is to be obferved. The depravation of the talle, which is in fome meafure charadleriftic of the plague, I have already had occafion to notice. *f The anxiety in many cafes is extreme, the patient conftantly changing his pofture, and foon finding the prefent as uneafy as the laft, 10 that he is fometimes perpetually in motion. When this fymptom is conftderable, it affords a very unfavorable prognofis. The appearance it affumes when at its height, which generally indicates the approach of death, is defcribed by authors, who have termed it a mortal inquietude, in very ftrong terms; The patient in-cefTantly twifts his body as if in agony, but is incapable of giving any account of his feelings, fo that it is difficult to determine whether it is occafioned by a great degree of anxiety or fevere pain.
> , " The temperature, in the progrefs of the difeafe, is various.
"While the chills continue to recur, its increafe is not confiderable, and in the cafes where it is molt confiderable, it feldom equals that which we often meet with in common fynocha. ?f The ftate of the pulfe is alfo various. In molt cafes after the firft days of the difeafe, in many after the firft hours, and in fome from .the commencement, it is feeble and frequent. Sometimes it is remarkably hard and fmall, but regular, at other times it is irregular or intermitting, and at length fluttering. " During the exacerbations, it often becomes full, open, and ftrong, as Dr. Ruffell exprefles it; after which it again links; but in a more advanced ftage, a different change is obferved during the exacerbations, the pulfe becoming fo feeble that it can with dit-,?culty be felt. " It has been obferved of the pulfe in the plague, that though to a flight touch it is ftrong and full, it is often eafily compreffed; a ftate of the pulfe not readily accounted for, which is mentioned however by more than one author from their own obfervation. The moft ftriking fa?t relating to the ftate of the pulfe in the plague is, that it has often been qbferved nearly natural while the other fymptoms indicated much danger.
./ '* As the difeafe advances, the increafe of debility is generally indicated by a confiderable affe&ion of the fpeech ; in fome cafes amounting only to a degree of confufion and faltering, or a change of tone; in others the voice is greatly impaired or wholly loft. ? The affeftion of the voice appears the earlier, the greater the debility. When this is exceflive from the beginning, when, as Chenot obferyes, ' ^Egri erefti ftarp aut federe impotes, proprio pone 4er? Iabebantur,' a confiderable affe&ion of the fpeech is generally pbfijrved * all along regular, with others in which there had been no (tool, ' the former did not appear to have been particularly exempt c from thofe fymptoms which might plaufibly have been imputed * to coftivenefa in others.' " The urine is often obferved in no refpeft different from that of a perfon in health ; at other times it is found pale, high coloured, clear, turbid, without fediment, or with a great deal, and fometimes more or lefs tinged with blood ; in fhort, it afiumes in different patients, or fometimes in the fame at different times, all the various appearances obferved in other fevers.

"
There is no excretion of fuch confequence in the plague as that by the fkin. When the fkin remains parched, or when only flight, clammy, partial fvveats appear, the prognofis is bad ; when on the other hand a thin, general, and copious fweat takes place, it often proves more or lefs critical. " Dr. Ruff 11 obferves, that 1 he breath and perfpiration were feldom or never fetid. Other writers, however, have oblerved, that they are often fetid to a great degree. " As in many, perhaps in all the other exanthemata, epileptic fits now and then occur They*are a rare fymptom in the plague. When they appear, they generally precede an eruption. " Slight convulfive motions of .the limbs and fublultus tendinum are frequent; with refpeft to other convulfive motions, hiccup rarely, and fneezing almoft never, attends the plague. ' " Hemorrhagies are a common fymptom, and unlefs very moderate, generally indicate much danger. They are frequent, as appears from what has been faid, from the ftomach, inteftine.-, and kidneys. They are more common however from the nofe, and in women from the uterus, than from other parts. Thefe, particularly the hemorrhagy from the nofe, when they occur early in the difeafe, and the patient is young and plethoric, fometimes bring relief. At a later period, hemorrhagies are always unfavourable, and when they become profufe, the patient feldcm recovers. It has been remarked, as might have been inferred a priori, that the blood which flows in thefe hemorrhagies is thinner in proportion as the difeafe is further advanced.

*'
Such are the fymptoms of the worfi form of the plague. The ftrength gradually finks, till the pulfe imprefles the finger with only a weak, undulating, or tremulous motion, with fiequent intermiffions. The furface, particularly on the extremities, becomes cold and covered with clammy moifture, the pulfe cannot be felt, and the patient calmly expires, or, as frequently happens in all idiopathic fevers, is carried ofr by convulfions.