in his First Lines, stated that in the misplaced gout, the disease is to be treated by bloodletting, and by such other remedies as would be proper in an idiopathic inflammation of the same parts; and in his lectures he was accustomed to observe, "What I call the misplaced is more immediately connected with the regular gout; it is where an inflammatory state takes place, and that inflammation is not in the joints, but in some of the internal parts, whose functions are of more immediate importance. What I have to say with regard to it is, that as far as writers upon this subject have been clear and distinct, and I have been told that they are not so always, this case of misplaced gout is attended with the same symptoms as attend the idiopathic inflammation of the same viscera; and so we have the peripneumonia arthritica of Sydenham and Musgrave; and at the same time we learn that it is attended with all the symptoms of inflammatory peripneumony; and as this is generally and universally the case, I can discuss the matter by further adding, that they also agree in this, that it is to be treated by the same remedies, chiefly by venesection. I have given," he adds, "the difficulties which occur with regard to venesection in regular gout; perhaps somewhat of the same doubts might occur here, but we are not thus to deliberate, we are under the strongest temptation and necessity of hazarding all the consequences of bleeding with regard to the constitution in general, when life is immediately at stake."

The descriptions which Dr Cullen has given of the diseases comprehended under his third order of Pyrexiæ, the Exanthemata, were, for the period at which they were written, uncommonly correct, and appear to have been all greatly improved by the results of his own observations and experience. The rules, also, which he has laid down with regard to the treatment

of these diseases, and in particular with regard to the use of bloodletting in Measles and Erysipelas, are extremely distinct, judicious, and important.

With respect to the supposed eruptive fever, which had been described under the name of Miliary Fever, and imagined to have appeared for the first time in Saxony about the middle of the 17th century, Dr Cullen, while he gives an account of what he found delivered by authors who had considered the white miliary fever as an idiopathic disease, declares, for his own part," after having often observed the disease, I must say that I doubt much if it ever be such an idiopathic as has been supposed; and I suspect that there is much fallacy in what has been written on the subject." Dr Beerenbroeck, in writing to Dr Cullen, soon after the publication of the second volume of the First Lines, says, “I have lately sent a paper on the Miliary Fever to the Medical Society, which is to concur for the prize to be awarded next August. The question is, Whether there exists a Miliary Fever as a primary affection, and distinct from the other exauthemata? Your treatise on the Miliary Fever has been of great service to me, and I find your opinion confirmed in a book just published by the successor to the late Dr De Haen (Stoll), who proves, from observations made at Vienna, that it is not a primary and distinct disease; that it is not contagious," &c. And after transcribing a few lines from Stoll's Ratio Medendi, he adds, "I will make no other reflection upon the extract, than that most of his observations confirm what you have delivered in your treatise on the Miliary Fever." I have inserted in the Appendix

(Note I.) a letter in which an opposite view of the nature of Miliary Fever is adopted, that was addressed to Dr Cullen by one of his early and favourite pupils, Dr Francis Hutcheson, son of the celebrated professor of Moral Philosophy in the University of Glasgow, and who was at that time a distinguished medical practitioner in Dublin.

In recognising the Hæmorrhages as an order of the class Pyrexiæ, Dr Cullen, as we have already seen, included under this title only those cases of sanguineous effusion that are attended with some degree of pyrexia, that seem always to depend on an increased impetus of the blood in the vessels pouring it out, and that arise chiefly from an internal cause. From this order he excluded, therefore, not only those effusions of red blood that are owing entirely to external violence, but those also which, though arising from internal causes, are not attended with pyrexia, and which are seemingly owing to a preternatural fluidity of the blood, and to the weakness or erosion of the vessels, rather than to any increased impetus of the blood in them.

As an essential foundation for a general doctrine of Active Hæmorrhage, Dr Cullen endeavoured to mark the order in which the several phenomena of this state succeed each other, as consisting of, 1st, Those indicative of fulness and tension about the parts from whence the blood is to issue; 2d, Those indicative of the state of Pyrexia, the cold stage followed by a

* See Appendix to vol. i. p. 583.

hot stage, in the course of which last the blood bursts forth; and, 3d, The spontaneous cessation of the effusion, and, along with it, of the hæmorrhage.

In the view of hæmorrhage taken by Stahl, the effusion of blood was regarded as the immediate and necessary consequence of a congestion of blood in a particular part, which congestion was in its turn attributed to motions excited, in a plethoric system, by the Soul for its own wise purposes. Hoffmann, in his explanation of active hæmorrhages, had interposed the occurrence of febrile action between the states of simple congestion and of hæmorrhage; and in this view he was followed by Cullen. Dr Cullen endeavoured, however, if not to trace, at least to lay a foundation for tracing, the sequence of events between the occurrence of congestion in a particular part, and the production of fever, and its attendant increased action of vessels, by a reference to the vires medicatrices Naturæ.

To explain the production of that unequal distribution of blood in different parts of the body, out of which local congestions arise, and which, as has been seen, was attributed by Stahl to tonic motions excited by the Soul, Hoffmann availed himself of the doctrine of constriction of the extreme vessels, which he had applied to fever, and arrived at the conclusion that fever and hæmorrhage are produced by the same motions; the only difference being, that in fever these motions are more, and in hæmorrhage less complete. Dr Cullen did not limit himself to constriction of the extreme vessels as the only morbid condition which may form the first link of the proximate cause of hæmorrhage;

but conceived that the remote causes which give rise eventually to hæmorrhagic effusions, may operate primarily on the vascular system, either by producing increased contraction or increased distention.

rence.

An important part of the general doctrine of hæmorrhage, on the explanation of which Dr Cullen bestowed much pains, is its liability to frequent recurThis circumstance he endeavoured to explain upon two principles; first, That though the flowing of the blood relieves for the time the existing congestion and consequent irritation, yet the internal causes by which the unequal distribution of blood was originally produced, commonly remain, and must now operate the more readily, as the over-stretched and relaxed vessels of the part will more easily admit of a congestion of blood in them; and, second, That hæmorrhage has always a tendency to increase the general plethoric state of the system, which state renders every cause of unequal distribution of blood of more considerable effect than it would otherwise be. The tendency of hæmorrhage to increase plethora, Dr Cullen supposed to depend on the ordinary excretions being suspended by the hæmorrhagic effusion, and not restored in time to counteract the renewal and further accumulation of blood.

But the part of the general doctrine of hæmorrhage, on the elucidation of which Dr Cullen seems to have bestowed the largest share of attention, was the liability of hæmorrhages to happen in certain parts of the body more frequently than in others, and at certain periods of life more readily than at others; why epistaxis, or hæmorrhage of the nose, should be so fre