COMMENTARIES HISTOEY AND CURE OF DISEASES. BY WILLIAM HEBERDEN, M.D. r»gl»V,KXl KOLfAVtlV OVKtTI JuVX/UiVOt, TOI/TO TO 0tG\lOt iy^tt^tt, ^UVTct^cCl Tltf (JUT* woAAhc TyCtit tv Titi; ruv **6g»;raiv voo-oif xATXhh^uvttt f*oi irti£ctt. ALEX. TRALX. LIB. XII. FROM THE LAST LONDON EDITION, PHILADELPHIA: ED. BARRINGTON AND GEO. D. HASWELL. 1845. \MB tVW5ons once 52 HEBERDEN'S COMMENTARIES. or twice every year, being preceded by shiverings and a hot fit, like an ague. This inflammation continues troublesome for seve- ral days at least, and will often end in an obstinate and ill-condi- tioned ulcer, which no art can heal for many years. These disorders are not always owing to internal causes, but have sometimes appeared in consequence of external hurts of the legs, by which they have been weakened, or otherwise injured. Women are far more subject to all these diseases of the legs than men (ex- cept perhaps that erysipelatous inflammation, which lasts only a few days or weeks). Healthy young women will often have their legs swell cedematously, especially in hot weather, which never happens to the young and healthy of the other sex. Pregnancy rarely fails to occasion this sort of swelling. A redness of the whole leg, with the skin thickened and hardened, and itching insufferably, with a great discharge of a sharp water, is very common among women after their fortieth year, remaining incurable for several years ; with which complaints fewer men are molested ; and the same may be said of ulcers of the legs. If then these swellings and inflammations, and ulcers, be almost peculiar to the legs, and chiefly incident to those, who from their age, or sex, or accidental hurts, may reasonably be supposed to have less firmness either in the textures of their whole bodies, or of this particular part, it should seem a right practice to add an addi- tional strength by bandages and straight stockings : and how safely this may be done appears from the total vanishing of the tumour by a horizontal posture, without any apparent injury to the health; and from the ready healing of the inflammations and ulcers in many cases, where they were probably occasioned by weakness. But it undoubtedly happens that the morbid quantity, or quality of the humours, are no uncommon causes of the swellings and sores, which therefore cannot safely be repelled by violent means. An asthma, probably arising from water in the breast, which threatened every moment to be fatal, has immediately taken a more favourable turn as soon as the lower parts of the body began to swell; and a sense of internal heats, with many disorders of the stomach, and other parts, have found as great relief by the formation of an ulcer in the leg; on the other hand, the healing of an ulcer in this part, has been followed by headaches, giddiness, numbness, shortnesses of breath, loss of appetite, and pains of the stomach and bowels. A due attention to the present habit of the patient's body, and to his former state of health, will afford the best direction to the physi- cian's judgment in deciding, whether it be safe to cure these dis- orders, or necessary to let the present evil remain, in order to pre- vent a greater. The Rochelle, or any other of the purging salts, given twice or three times a week, so as to purge not more than thrice : two scru- ples of the Peruvian bark taken every day at any convenient hour • and, if there be occasion for any thing further, a quarter or a third or part or half a grain of calcined mercury, with a scruple of crude CUTIS VITIA. 53 antimony swallowed every night, or every other night, will perhaps answer all the purposes of evacuating and correcting the morbid hu- mours. They may be continued, if they be so long wanted, for two or three months. An issue above the knee has been judged to con- tribute sometimes to the cure or prevention of an ulcer in the leg ; and in other cases it has been useless. CHAPTER XXIII. Cutis Vitia. There is a great variety of cutaneous disorders. The several dis- colourings of the skin, brown, yellow, black, and blue, hardly de- serve to be reckoned among its diseases, where they neither rise above the level of the other parts, nor are attended with any un- usual sensations. It may however be worth the mentioning, that I have seen some children with little purple spots, like the purples in bad fevers, all over their bodies, except that in some places there were larger patches of them as broad as the palm of the hand, un- accompanied with fever or any other alteration of their health, which after a few days spontaneously vanished.* In old people, blue spots, about a quarter of an inch broad, are not uncommon. Small pimples frequently rise, and soon die away without spread- ing; but they sometimes spread into a branny, or scaly blotch, or turn to a thick crust, cracking in various places; whence a water oozes out, with which the legs and face, and more rarely the whole body, are covered, with equal deformity and inconvenience. Erup- tions, or risings above the skin, are red, or of the same colour with the skin, moist or dry, watery or purulent, smarting or itching, and sometimes without either. The nails too will become rough and thick and scaly. Pustules will arise so large as to approach the size of biles, which they resemble. A heap of small watery pim- ples, after they have broken, have been known to leave a speck of blood, like the point of a pin, with itching and swelling. Several of the appearances here mentioned have been distin- guished among the ancient physicians by peculiar names: there is great difficulty, though happily not much use, in ascertaining the ap- pearances to which these names were appropriated ; for this reason the ancient divisions and titles of cutaneous diseases are very little regarded by the moderns. Almost all affections of the skin, which have no other name, are vulgarly, with great impropriety, called the scurvy. Of the true scurvy and leprosy I can say nothing, as they have never occurred in my practice ; beside these, the itch, shin- gles, and scald-head, are perhaps the only chronical cutaneous ails, for which we have names, in which all are agreed. Several of these maladies are hereditary: and even where they are not derived from the parents, they may still be the effects of a general disorder of the body, rather than merely local, and belong- * 6*e»: chapter Ixxviii. 54 HEBERDEN'S COMMENTARIES. ing only to the skin. Cutaneous ails, brought by some children with them into the world, have continued with very little interrup- tion to the end of a long life. After the measles and small-pox, dis- orders of the skin will make their appearance in some, who never had any of them before: it remains a doubt, whether they have been formed by some mischief arising from these diseases, _ or whe- ther they have only been excited from latent seeds pre-existing in the body; or lastly, whether their appearance at that time be not wholly casual: since it happens more seldom, than it probably would, if the small-pox and measles had a natural tendency either to breed any disease in the skin, or to nourish them. The spring of the year is the season in which they are most apt to appear, or to grow worse ; and next to this may be reckoned the autumn ; but this is by no means constant. There is still much greater uncertainty with regard to summer and winter ; so that it is hard to say whether more diseases of the skin be exasperated, or relieved, by either of them. The warmth of a bed, and of a fire, has made some spots of the skin retreat, which never failed to re- appear in proportion as the body was cooled ; the contrary to this has been experienced in several instances, and perhaps in more. A moisture behind the ears is common in children ; and this, whe- ther from neglect of keeping the part clean, or from the abundance and sharpness of the humour, will sometimes spread all over the head and face. The branny scurf, which is often observed in seve- ral patches all over the body, is very apt to begin at the point of the elbow. A violent itching of the skin without any eruption is fami- liar to the jaundice, and adds sometimes to the discomforts of old age.* Several women have had a pimple appear on their noses, which has been succeeded by a thick scab, covering, by degrees, the nose, face, and neck; and has for many years eluded every method of cure which a variety of physicians was able to suggest. This appearance is much less common, though not altogether unknown, in the other sex. A branny scurf in various parts of the skin, and particularly in the head, has infested some through their whole lives. There seems to be very little if any contagion in cutaneous dis- orders, if we except the itch and scald head. A woman, who had for five years had broad branny eruptions, suckled a child whose skin remained perfectly clear from any disorder. The itch is well known to be very infectious; but there is an appearance exactly like it, and which could be traced up to its having been received from an infected person, and yet differs from the true psora by being very little, if at all infectious, by its resisting all the usual remedies and by its returning frequently for many years. While the ears are swelled and red with a great watery discharge from behind them it is very common for the lymphatic glands to be swelled, as they often are for a few days after a considerable discharge has been procured from the neighbouring parts by a blister. Many morbid appearances of the skin are judged to be proofs of * See afterwards chapter Ixxvi. CUTIS VITIA. 55 a diseased constitution, rather than merely local disorders of the part which is afflicted with them; yet in some instances a hurt of the skin by a bruise or a burn has been the cause of a general mischief; so that in consequence of such an accident a clear habit of body has in an advanced age of life shown all the marks of what is vul- garly called a scorbutic or even strumous taint. There are also other instances where cutaneous maladies, instead of relieving, have al- ways hurt the general health, never failing to be accompanied with headaches and languors, which increased and decreased with the eruptions. Such cases however are rare ; and the reverse is much oftener met with, where some general ail of the body throws itself off in blotches and deformities of the skin; so that when these re- treat of themselves, or are repelled, the patient will complain of headaches, giddiness, lowness of spirits, want of sleep, cough, want of appetite, heart-burn, flatulence, sickness, pains of the stomach, wandering pains, feverishness, and wasting of the flesh. It is a doubt, whether some asthmatic, consumptive, and paralytic com- plaints, have been the effect of cutaneous distempers ceasing to ap- pear, or whether both of them have been owing to some common cause; for it has been not improbable, that some fatal mischief arising from other causes had so weakened the powers of life, that nature was unable to free herself any longer from that incumbrance which she used to throw off upon the skin. The moisture so common behind the ears of children, during the first four years of their lives, requires only to have the parts kept clean with a little warm water, and to be hindered from growing together by means of a fine rag smeared with any mild ointment; but all further application should be avoided, as having been some- times attended with convulsive fits, shortness of breath, and other bad consequences; whereas none need be feared from suffering the disorder to take its own course, and from trusting to its curing itself, as soon as it is for the patient's benefit that it should be cured. Where mischief has ensued from repelling these eruptions in chil- dren by violent means, a slight anointing of the parts, which had been affected, with the blister ointment, will be an useful method of recalling them. In adults there is usually less danger, than difficulty, in freeing the skin from the several blemishes to which it is liable. There are too many so deeply rooted in the constitution, as to elude all the known external and internal remedies ; and they are often supposed to be cured when they are not; for it is hard to determine whether they have yielded to the remedies, or have spontaneously retreated; which they have been known to do, and to be latent for above twenty years, after which they have returned with unabated vigour; plainly showing that the cause had been neither subdued nor weakened. Where the perspiration is great, and confined, as in the groin, under the breasts of women, and in the necks and other parts of very fat children, it is apt to grow acrid, and to fret the parts on which it lies ; the frequent washing of them, and the use of any soft oint- 56 HEBERDEN'S COMMENTARIES. nient to prevent their rubbing against one another, will prove effectual remedies. During pregnancy many obstinate cutaneous maladies have been known to disappear spontaneously, which had long resisted all the usual medicines ; but after delivery they have returned in their former manner. There has been reason to be- lieve that issues and blisters have in several instances proved useful drains to those morbid humours which made the skin foul and unsightly ; but in others no benefit has seemed to arise from them. With regard to external applications, it is an useful general rule to employ acrid washes and unguents, where the diseased skin is accompanied with itching ; but Where it is attended with soreness and pain, to use such mild ones as may mitigate rather than in- crease the smart; otherwise, troublesome and even dangerous in- flammations might be brought on. Water is the gentlest of all ex- ternal remedies, whether it be made a cold or warm bath, or ap- plied in fomentation and vapour. It dilutes and weakens any sharp moisture which, by fretting the skin, may increase the evil; and by suppleing the scales and crusts, makes them more easily thrown off. Salt, sulphur, and various herbs, are sometimes added to improve its detersive powers ; hence the sea water, and many natural springs, are judged more efficacious than plain water. Preparations of lead, though void of all acrimony, are in such general esteem as external cutaneous remedies, that they are not only used to the disorders at- tended with heat and some degree of pain, but also to such as only itch, or are perfectly indolent. Extracts of lead made with vinegar, ceruse, and sugar of lead, formed into washes, ointments, and plais- ters, are all in frequent use ; and it is not easy, from any experience which I have had of them, to say which of these preparations is preferable to the others. The tar ointment may likewise be applied not only to such blotches as itch, but even to those where there are cracks and moist sores, without any fear of increasing the pain in most cases ; but in a few instances it has been known to dry, and create pain. Sulphur has a specific virtue in curing one distemper of the skin, and there are few others in which it has not been tried externally and internally. The success, whatever it may have been, has by no means been so great as to hinder our doubting whether it have any, except in curing the itch. The seeds of staves-acre, and the root of white hellebore, are both extremely acrid, and require so much caution and accuracy in the dose, that they have very rarely been ventured upon as internal medicines ; but when applied out- wardly, they are safe and effectual in a degree, which may make it probable that, besides their acrimony, they have some specific pow- ers in clearing the skin from foulnesses. One grain of white helle- bore may be safely given internally, but I know nothing of the in- ternal use of staves-acre : half an ounce of the seeds of staves-acre powdered, may be infused in half a pint of boiling water to which after it is cold, should be added as much brandy, and the parts af- fected are to be washed morning and night with the strained liquor. A lotion, applicable in the same manner, may be made by pouring CUTIS VITIA. 57 twenty ounces of boiling water upon four or six drams of the pow- der of white hellebore root, and by adding to the strained liquor four ounces of the tincture of the same root. The only ill effects of which I am aware from these lotions is the pain and constant in- flammation which they may occasion ; this will easily be remedied by lowering them with more water, till the heat and pain become moderate. There is such a difference of soundness and freshness in different parcels of these drugs, that there is no other way of exactly proportioning the quantity of water but by some help from trial; not to mention the various degrees of sensibility which is to be found in the skins of different persons. They may also be used in ointments, by mixing them with four times their quantity of simple ointment. Pepper, and many other acrimonious simples, have a place likewise among cutaneous remedies: upon this account cantharides in oint- ments and plasters have been used to clear the skin from its diseases; but I have not been witness to their virtues for this purpose often enough to be sufficiently acquainted with them. Solutions of alum and of vitriol, will allay a troublesome itching of the skin which comes without an eruption, and will also destroy the half-dead scales, and clear the skin from several blemishes. The strength of these solutions must be limited by the pain and inflammation which they occasion: while these are slight, they can never be too strong, the same rule holds with regard to all the other acrimonious remedies for the skin. Quicksilver, besides the corrosiveness of its preparations, appears to have some peculiar powers in destroying the causes of some cuta- neous maladies. Crude quicksilver, which is perfectly mild to the touch, when divided with any tenacious substance, and applied in ointments and plasters, has been found considerably efficacious in cleansing the skin from many foulnesses. The chemical preparations of it add greatly to its powers, by the degree ot acrimony which they possess. The neatest of all these, but at the same time the most violent, is the corrosive sublimate, because it perfectly dis- solves in water, or spirits of wine, and has neither colour nor smell. The others, being indissoluble in water, must be applied in un- guents and plasters. It must always be remembered, that besides the caution necessary to prevent pain and inflammation from the more acrimonious preparations of mercury, there is another thing to be attended to in the use of all of them, which is, not to em- ploy them in so large a quantity as to occasion their peculiar effect of salivating. One dram of corrosive sublimate will generally be sufficient for a pint of water ; half an ounce is much too large a quantity; and 1 have known great pain and swelling ensue from washing a very small portion of the skin with so strong a mercurial lotion. The corrosive sublimate should be dissolved in pure water preferably to lime water, which only weakens it, and gives it a dis- agreeable yellow colour. With regard to the probability of exciting a salivation, there will be a great difference, arising from the large- ness of the surface of the body to which the mercurial medicine is S 5S HEBERDEN'S commentaries. applied. A very weak preparation spread over a large portion ol the body, would be much more likely to raise a salivation, than a much stronger which covered only a small part of it. 'I he unguen- tum hydrargyri nitrati has been anointed over the whole face every day for many days together, without any complaints either of pre- sent pain, or consequent salivation. How innocent a mercurial oint- ment may be made with one dram of the calx hydrargyri alba and one ounce, or half an ounce, of simple ointment, may be judged from the free use which is safely made in surgery of that stronger preparation, mercurius nitratus ruber. Magistery of bismuth, and flowers of zinc, either sprinkled upon the skin, or formed into an ointment, are rather cosmetic, than remedies for any harm conside- rable enough to be called a distemper. The internal medicines are either such as evacuate the diseased tumours or correct them. Strong purges are improper for the first of these purposes, and will sooner exhaust the patient's strength than expel the cause of the distemper. A long continuance of the gen- tler purgatives is best calculated to suit the obstinate nature of the diseases of the skin. The experience of mankind seems to have settled in preferring the purging salts as the most safe and commo- dious medicines of this class. They neither pall the stomach, nor require confinement; and are so far from impairing the strength, that weakly persons have grown fatter and stronger during a twelve- months daily use of sea water. Whether they are best taken in sea water, or the natural solutions of various springs, or the artificial solutions in common water, and which of the neutral purging salts is the most friendly to the body, and most powerful against the dis- temper, all this seems to remain undecided by any experience with which I am acquainted. They should not be given in such a dose as to purge above twice, and during their use frequent attention should be given to the state of the patient's strength and flesh ; for if these begin to be impaired, the purging ought to be laid aside. A great variety of internal remedies for correcting the unhealthy humours which show themselves upon the skin, are to be found in all practical books of physic. Among all these the Peruvian bark and mercurial preparations have appeared to me to do the most good. In the less urgent cases a dram of the powder of the bark must be taken once a day, or two scruples twice a day, for several months ; and I know it may be taken for a very long time with great advantage to the general health, besides its virtues in clearing the skin. There has been very great reason to believe that it has mended the appetite and digestion, and prevented catarrhs. In more violent disorders a quarter of a grain of calcined mercury has been given every day for three or four months with safety and benefit. A solution of corro- sive sublimate, containing half a quarter of a grain, may be used in the same manner. This method of cure has, as far as I could judge proved the most successful; but it will happen, I fear to all the known methods, that they will be found too weak to subdue the obstinacy of some inveterate cutaneous diseases. CUTIS VITIA. 59 The herpes, or shingles, has begun with a pain which has lasted in some for two or three days before the eruption appeared. It con- sists of a heap of watery bladders, itching at first, of which there are sometimes so many as nearly to surround the body, whence it has its name of shingles, from cingulum. This eruption is now and then attended with a fever. The bladders should be opened, and the sharp serum let out, after which the parts may be covered with a soft cerate, to defend them from the rubbing of the clothes, for they are sometimes very painful. It seldom happens that these little blisters turn to obstinate sores, though in old persons, and in bad constitutions, it will be several days before they are quite healed. But the greatest part of the misery is many times to come after they are perfectly well, and the skin has recovered its natural appearance ; for I have known a most pungent burning pain left in the part, which has teazed the patient for several months, or even for two or three years ; nor have I found that any soothing or opiate application ever gave much relief. The uneasy sensation which succeeds the herpes has in some arisen only to a torpid feel. In one person, in whom the herpes had broken out near the collar bone and shoulder, such an exquisite tenderness was left, that he dreaded to move his arm, and could hardly bear the application of anything to the part, though made with the lightest feather : he was obliged to cover himself only with a loose gown, having, when I saw him, been unable for two or three years to put on a coat. However, this was the only instance in which I ever knew the pain rage with such extraordinary violence. In a woman more than fifty years old the herpes appeared upon the right clavicle, together with fever, and pains throughout the whole right arm. The eruption and fever continued some weeks ; but the skin remained scaly for several months, and the whole arm became gradually weaker, till it lost all power of spontaneous mo- tion ; and in this state it continued at least for three years, and pro- bably for her whole life. The fingers were constantly in an involun- tary tremor. The porrigo, or scald head, begins with little spots of a branny scurf, which itch and grow bald ; these gradually become larger and more numerous, till they cover the whole head, the skin of which will be sometimes so deeply affected with the humour as to be full of moist sores or scabs. Children are more subject to this complaint than adults, and boys more than girls. Among grown persons, I have seen several women labouring under this complaint, and but few men. It is an infectious distemper, and readily communicable where children use the same combs, or pillows, or put the same covering on their heads with the infected person, or hold their heads close to his ; but when all these circumstances are cautiously avoided, I have known children live and play together in the same house, and yet one who had a scald head did not give it to the rest. In some constitutions it seems as if certain diseased humours were thrown out and appeared in the form of a scald head ; so that a cough has immediately ceased upon its coming on, and when it re- 60 HEBERDEN'S COMMENTARIES. Of treated the breathing has become short and laborious. . A species this disorder has broken out during the infancy of some women, anu has continued upon them to old age without yielding to any _meai- cines. There is no little difficulty in curing it, in children, tn°uS" it may have been recently contracted; and every one must nave heard of such who have been under very skilful management tor two or three years without the desired success. The best method, which I know, is to cut off the hair where the distemper has spread over a great part of the head, and to keep it anointed with the tar ointment, covering it with a hog s bladder. If it heal by means of this application's it often does, though it may be two or three months before it be well, I then recommend the head to be wetted morning and evening with the infusion of white-helle- bore root above mentioned, as long as any tendency to scurf is seen. If there should be any part of the head where the skin is more deeply diseased so as to form a sore, one dram of the calx hydrargyri alba mixed with half an ounce of a soft cerate makes an useful ointment, some of which spread upon a piece of thin leather may be applied, and renewed as often as it grows too dry to stick on any longer. Where a healthy person has manifestly contracted this distemper from others, I know of no want of any internal medicines. The scabies, psora, or itch, appears most commonly like very small watery pimples, but sometimes resembles the smaller variolous pustules, having a red base, and being filled with a yellow matter. Both these appearances are attended with excessive itching, and are found chiefly about the joints, and particularly between the fingers ; but very remarkably spare the face ; so that I am not sure that I ever saw the least marks of it there, though once or twice I have been in doubt whether the face has not some little share of it. No distemper is more infectious than this : but it has before been men- tioned, that there is a species of it, which was at first catched by infection, and though seemingly cured by the proper remedies, yet will continue to return once or twice every year, without being con- tagious even to those who lie in the same bed, and without retreating at all the sooner from the application of any of the usual remedies. The itch has been imputed to certain animalcules. I was told by that very dextrous experimenter, and accurate observer, the late Mr. Canton, that he had looked for them, but had never been able to satisfy himself that there were any. I have heard the same from Mr. Henry Baker, whose well-known treatise upon the microscope shows that no one was better skilled in its use. It is observable, that of infectious distempers, some, like the small- pox or measles, can be had but once ; or very seldom oftener, as the malignant sore throat, and hooping-cough ; or only in particular cir- cumstances, or certain constitutions of the air, as the dysentery, camp-fever, and plague : but the itch and the Venereal distemper are very generally communicable at all times to all persons who come in the way of their contagion. It is not easy to say what would have been the state of mankind, if out of the three specifics with which CUTIS VITIA. 61 Providence has blessed us, two of them had not opposed the universal infection with which these two disorders would otherwise have over- spread the whole world. There is a vulgar notion in some countries, that the itch is whole- some, and that there is danger in curing it too soon : this is almost too ridiculous to be mentioned; and yet I believe there is as much foundation for it, as for that more respectable, because more general, notion of the wholesomeness of the gout. The remedies for this dis- temper are in the first place sulphur, which has a specific or peculiar power of curing it, and is always safe, and can never be applied too soon, and therefore is preferable to all others ; but it is often objected to on account of its smell, and of its being less neat than other reme- dies. The most common way of using it is by mixing one part of flowers of sulphur with four parts of lard, and anointing the parts once every twenty-four hours. A cure is by these means usually effected in about ten days. A shirt being lightly sprinkled with the flowers of sulphur is said to be equally effectual; and the late Mr. Cheselden told me, that the distemper would be cured if the feet only were anointed, without applying the ointment to any other parts of the body which have suffered from the itch. Crude quicksilver seems also to possess some specific powers; for if it be divided by white of egg, or any tenacious substance, and soaked up by flannel, or if the unguentum hydrargyri be spread upon linen or leather, and worn round the body in the form of a girdle, this application will frequently be successful. And yet, what is very extraordinary, it is not uncommon for persons to rise from a saliva- tion, uncured of the itch, notwithstanding their having been con- stantly daubed with the mercurial ointment for a month or six weeks. It is doubtful whether the chemical preparations of mercury prove remedies on account of any specific virtue, or merely from their cor- rosiveness, which reduces these little foul sores to a state of healing, just as any other ill-conditioned ulcer is brought onto heal by similar means. The neatest of all these preparations is a solution of one dram, or at most two drams, of corrosive sublimate in one pint of pure water, with which the distempered parts may frequently be wetted. One dram of white precipitate mixed with four times its quantity of ointment, makes also a safe, and not an offensive medi- cine, which may be applied every night. Some persons have com- plained of lowness of spirits, pains of the bowels, and wandering pains, after being cured by the help of these girdles, washes, and ointments, which they laid to the charge of the mercurial ingredient. But since very few of those who have been cured by the same means have reason to suspect any thing of this kind, and since a much freer use is made of mercury upon several other occasions without any of these ill consequences, it is most probable that these patients were mistaken in assigning this cause of their complaints. The root of white hellebore is preferred by some, as having no smell, being perfectly innocent, and seldom failing of success. Medi- cines prepared from it should be made so strong as to occasion some 62 HEBERDEN-S COMMENTARIES. smart, but no inflammation : this will commonly be effected by one part of the powdered root and eight parts of ointment, used in the same manner as the sulphur ointment. The decoction or infusion of the same root, as mentioned above, will make a wash, which, used like the mercurial wash, will very rarely disappoint the patient. CHAPTER XXIV. Destillatio. It was necessary that the throat, and mouth, and nose, and eyes, should all be kept in a state of moisture ; for which purpose a liquid is secreted from certain glands and glandular membranes ; and if this become incommodiously copious, it is called a catarrh or de- fluxion. This seems to arise sometimes from a too great weakness or relaxation of the secreting organs ; and sometimes from an abund- ance of superfluous humour, which nature can more easily discharge by these outlets; or from the acrimony of the liquid, which makes the eyes tender, or irritates the nose to perpetual sneezing, or the trachea to coughing with hoarseness, creating a pungent sensation in the mouth, and making all the parts sore over which it flows. When the catarrh affects only the eyes, or nostrils, and the cavities which open into them, it is not attended with any cough; but if its seat be in the glands of the throat, then there will not only be a cough in the day-time, but the defluxion will collect in such quantities during the first sound sleep before it wakes the person, that at last he starts up almost suffocated, and it is with great efforts that he clears the trachea so as to recover the power of breathing with tolerable ease : possibly some may have died suddenly, having been choked in this manner. A sudden sense of suffocation frequently attacks some persons, and it is with great and laborious efforts that they save themselves from being choked. Is not this affection a peculiar kind of convulsion ? and is not the thin froth which they expectorate in their struggle for breath, rather the effect, than the cause of this disorder ? If such a catarrh lasts only a few days, it is called a cold in the head ; but in many it becomes a chronical disorder, and has lasted with no long intervals for several months, for four years, or every night for ten years ; or has returned periodically twice a month for several years, or once in three weeks. I have known it return in four or five persons annually in the months of April, May, June, or July, and last a month with great violence. In one a catarrh con- stantly visited him every summer ; and in another this was the only part of the year in which it ceased to be troublesome. The state of pregnancy has several times been attended with this complaint: and I remember it to have once continued for four years after the preg- nancy. Irregularities of the menstrua, among other disorders of the health, have also been accompanied with an excessive flow of saliva; and hysteric women have been infested with it for two or three months, in a degree not inferior to that of a moderate salivation DEV0RATI0. 63 raised with quicksilver. A bad sore throat has in some persons been followed for a long time by a very troublesome degree of spitting. But the salivary glands are peculiarly affected, as is well known, by mercurial medicines ; after the use of which a considerable salivation has teazed some patients for many months, and in two or three it has continued frequently to return for above three years. iEthiop's mineral has several times had a similar effect; and in one who had taken it forty days a great spitting ensued, which lasted three years. Many women have, within my observation, suffered in this manner from mercurial preparations ; but I hardly recollect an instance of it in the other sex. Such extraordinary discharges of saliva have in a few instances evidently wasted the flesh and weakened the body; but have been often borne for a long time without any manifest injury of the health. A weight and pains of the head have so frequently been relieved by a great catarrh, that in such cases it may be considered rather as a remedy, than a disease, and therefore violent means should not be employed to check it. These pains with feverishness and a slight defluxion are in some years epidemical, occasioning a remarkable languor, at least for some days, which has hung upon some patients, together with night sweats and loss of appetite, for a long time, and has ended at last in a fatal pulmonary consumption, after a gradual decline for two or three years. An habitual catarrh has spontaneously ceased in the seventieth year of life, and also upon the coming on of a palsy ; but has been oftener known to end in an asthma. In many cases a variety of means has been used to stop it with very little effect. A spontane- ous discharge of thin lymph from both the outside and inside of the ears has been found to check a catarrh : and so has an artificial one made by a blister. The pilula? catarrhales of many dispensatories, consisting of aloes and opium, seem well calculated to divert the humour, and to soothe the irritation. The mucilage of quince seeds is very grateful, where the mouth is sore : where the glands are only weak and relaxed, the astringent decoctions of oak-bark, with alum dissolved in them, may have their use. A fit of the gout has super- vened a catarrh, without affording any relief. Two persons, for other purposes, took at least a dram of the Peruvian bark every day for many months, during all which time they were free from that sort of catarrh which is commonly called a cold in the head, to which they had both of them been remarkably subject. CHAPTER XXV. Devoratio. A child two years and a half old swallowed two round pieces of copper money : the diameter of one was one inch and one-tenth of an inch ; the other was a little less. She seemed very ill for the first week after, and was unwilling to take down any food ; which 64 HEBERDEN'S COMMENTARIES. might be owing to the soreness of the throat, which these pieces had occasioned in passing. After this time she frequently took a little castor-oil, and enjoyed her usual health, complaining of nothing. Twenty-nine days after she had swallowed these pieces, they were both voided by stool, and did not show any sign of rust or corrosion. The power of swallowing is weakened, and sometimes wholly lost, from various causes. In hysteric fits it is not uncommon to be un- able to get anything down ; and a difficulty of doing it has constantly attended some women every time of their pregnancy. It is often seen that spasms, from whatever cause they arise, will come on in the middle of eating, stopping for a little while the descent of any- thing into the stomach, and occasioning great efforts to clear the oesophagus, which force up much phlegm, but nothing of what had been before eaten. This has returned at very uncertain periods, once in ten days, or three or four times in a year, and has lasted in this manner for several years. The muscles serving to deglutition are also liable to be seized with a paralytic weakness, rendering them incapable of performing their proper offices. A still more dangerous species of this disorder arises from a strumous swelling of the glands, which happens in all parts of the oesophagus from the fauces to the cardia ; in consequence of which the swallowing becomes gradually more and more difficult, till it be at last totally obstructed. I have known the same fatal mischief happen to the respiration from the same cause. Besides these general incapacities of swallowing anything, there are partial ones, which respect only particular things. Some have been able to swallow any food, except meat; others have readily taken down liquids, but not solids ; and, what is more strange, in other cases solids have found a passage down into the stomach with much greater ease than liquids. Though I have had opportunities of frequently observing most of these complaints, yet I have not been able to satisfy myself that any means which I have used have proved peculiarly serviceable, above the general method of treating those distempers to which the complaints appear to be related. The use of nourishing clysters is well known, by the assistance of which time may be gained ; and this in some of these disorders is of the utmost importance. CHAPTER XXVI. Diabetes. The diabetes is a complaint which happily occurs but seldom • and hence, I imagine, it has happened, that the history of it in books is not very clear and precise ; nor has my own experience satisfied me in supplying their defects. I have scarcely had opportunities of observing twenty cases, where this was supposed to be the distem- per ; and some of these seemed not to deserve the name. In fevers which proved fatal, I have once or twice known the symptoms of a perpetual making of water, and in large quantities, with inextinguish- DIABETES. 65 able thirst. But the more usual manner in which this excess of urine shows itself, ranks it with chronical disorders. An unusual thirst is first taken notice of, with a tongue rough and furred, and a bad taste in the mouth ; the appetite fails ; the pulse is too quick ; the strength and flesh waste ; the skin is in a burning heat, without the least ten- dency to sweat; the thirst makes these patients drink immoderately, and of course they make water much more frequently than is com- mon to them, and in much larger quantities, like hysterical persons. The urine should naturally be about four-fifths of the drink ; but even in health it will fall considerably short of this now and then for the space of a day, and will sometimes exceed the whole of what has been drunk ; and when it does it will resemble common water more than urine, in its want of colour, taste and smell. The urine in a diabetes is said to have a honey-like sweetness ; but in my judgment, formed upon the most perfect cases of this distemper, it ought in most persons rather to be called insipid: in one, joined with a fever, I found it sweetish. An extraordinary flow of urine has been remark- able for some months ; and yet, when measured, has not been found to exceed the drink, which, on account of the thirst, is more than these patients are usually aware of. However, towards the end of the distemper, the urine will considerably surpass the liquor, so as to be double of what they have taken. This deviation of the urine from its natural state will continue sometimes more, and sometimes less, for three or four years, and has returned after seeming to be entirely gone. Though the excess of urine is the circumstance which has been chiefly attended to, yet, in every case of this kind which I have seen, the thirst has been first in time, and by far the most distressing, and what ought rather to have given name to the distemper; but, in truth, they seem both to be rather symptoms of the breaking up of a constitution, and have hardly ever been known but in very infirm and old people, in whom age or distemper had so far injured some of the parts necessary to life, that death must soon have ensued, whether the patient made too much water, and was wasted in a dia- betes, or made hardly any, and was bloated in a dropsy. It is not very improbable, that some trivial circumstance determined the body to take on one of these two diseases rather than the other, and that the removing of either of them would do but little towards saving the patient's life. If the diabetes be, as I am inclined to think, the symptom of some other distemper, and not the disease of any of the organs which se- crete the urine, the only useful remedies will be those which are directed to cure the principal malady, of which the diabetes is but an appendage. Accordingly it has appeared to me, that little good was to be done with alum, the Peruvian bark, elixir of vitriol, Bristol water, lime water, a repetition of emetics, or any other medicines, which were principally calculated to recover the kidneys-from their supposed relaxed state to their natural tone and firmness. • A young man, who had laboured under a true diabetes for twelve months, was 9 66 HEBERDEN'S COMMENTARIES. CHAPTER XXVII. Diarrhoea. A DIARRHEA arises from a variety of causes, most of which are void of all danger, and are easily removed. It is often brought on by that power, which is exerted in every part of the body, ot treeing itself from anything painful and oppressive. Not only the mischief from the noxious qualities, and improper quantities of what has been taken, and immediately offends the stomach, are carried off by means of a diarrhoea, but likewise many disorders of remote parts, or of the whole body (such as morbid impressions from the causes of epide- mical complaints, and of fevers), are by the self-correcting powers of an animal body determined to the bowels, and thence discharged by a diarrhoea. The observation of this has given occasion to that useful caution of not being too hasty in^topping a recent spontaneous purging, it being frequently useful to co-operate with nature in promoting this evacuation. For this purpose rhubarb has been chiefly recommended, and deservedly ; but instead of rhubarb I have many times given two or three drachms of the neutral purging salts, and think they have always done as well, and in some cases better, by making a more speedy and complete evacuation of what had offended the bowels, and with less sickness. An emetic is also successfully used where the nausea is very great; but otherwise I think a vomit is unnecessary. Fifteen grains of powdered ipecacuanha, or even half a pint of carduus or camomile-flower tea, will sufficiently answer this purpose. After what had oppressed the bowels has been removed, a weak or too irritable a state of them may still continue : hence arise indi- gestions, flatulence, heartburn, frequent returns of the diarrhoea, and a predominant acid in the stomach. The testaceous powders and chalk julep are the proper correctors of this too ready acescence of the humours; which therefore should be employed : but they will not alone be of much avail in stopping a diarrhoea which is considerable enough to require any medicines at all. Nutmeg, cinnamon, pome- granate bark, and many other astringent vegetable substances, are much more efficacious, but yet often require to be joined with reme- dies which soothe the too great irritableness of the intestines, namely, gum-arabic, starch, and opiates. Haifa dram of testaceous powder, fifteen grains of pomegranate bark, and half a scruple of nutmeg, with three drops of tincture of opium, may be taken in any distilled, or common water, once or twice a day in the more chronical and habi- tual purgings, or once in six hours in the more recent and violent ones. Tinctura opii mixed in any pleasant julep, so as to let the patient take as much as contains three or four drops after every purg- ing stool, is in many cases required : and besides this manner of giv- ing the opium, it is often extremely serviceable to give from twenty seized with an acute fever, and died. The body, which was carefully examined, showed no marks of disease. The kidneys were imagined to be rather fuller of blood than usual • and the gall-bladder was perfectly empty. — E. DIGITORUM NODI—DOLOR. 67 to forty drops in a quarter of a pint of mucilage of quince seeds, or of starch, administered in a clyster. Gum-arabic dissolved in water, or in milk and water, may be taken to the quantity of one ounce in twenty-four hours: and, lastly, one large spoonful of clean mutton fat, mixed with a quarter of a pint of milk hot enough to melt the fat, and drunk twice a day, is not only a good remedy, but nourishing food. This method has appeared to me the most effectual, where the diarrhoea was curable and needed to be cured ; but there are instances of its being habitual and harmless, at least for several years, and re- turning upon the slightest occasions for the greatest part of a person's life. I have seen an instance of a diarrhoea's continuing for three months at the rate of twenty times in a day without any apparent in- jury to the health. In such cases it is difficult, and perhaps hardly desirable, to affect a cure of what is not so much a distemper, as an inconvenience, which may be more than compensated by the benefit which it does to the general habit of the body. Where the appetite fails, and the flesh wastes, no time should be lost in checking the purging; but if neither of these be affected, a cautious delay, and gentle remedies, will prove the best means of restoring the patient. Among the many causes of diarrhoeas, there are some, though few in proportion to the others, which are neither to be checked by the milder, nor subdued by the more vigorous methods of cure, but end only in the patient's death, after having been in vain opposed, as is usual in desperate cases, by a variety of regular and irregular practitioners. In some of these the glands of the mesentery and intestines have been found schirrous; in others, though they were opened, and all the parts examined by the most experienced and dex- terous anatomists, the stomach and bowels have appeared in a natu- ral state, and no cause of the distemper could be discovered. I have not mentioned a sea voyage, nor the Bath, because I have known them fail so often, that I have no encouragement to depend upon them ; and rather think, where they have been supposed to be suc- cessful, that the success was in reality owing to other causes. CHAPTER XXVIII. Digitorum Nodi. What are those little hard knobs, about the size of a small pea, which are frequently seen upon the fingers, particularly a little below the top, near the joint ? They have no connexion with the gout, being found i'n persons who never had it; they continue for life ; and being hardly ever attended with pain or disposed to become sores, are rather unsightly than inconvenient, though they must be some little hin- drance to the free use of the fingers. CHAPTER XXIX. Dolor. Pain is a symptom attending upon a variety of disorders, and is 68 HEBERDEN'S commentaries. sometimes itself the whole distemper. It is distinguished sometimes by being periodical; sometimes it has a particular name from the part which is frequently its seat; as headache, hemicrania, lumbago. All other pats of the body, which have any sense of feeling, are ne- cessarily liable to pain, though they be not so frequently molested, as that the pain should be ranked as a distinct species with a particu- lar name. Accordingly, there is no part of the body, or limbs, in which I have not observed a troublesome and lasting pain without any discolouring, or swelling, or tendency to inflammation. It will remain fixed in the same place not only for months, but frequently from one to ten years ; and I have known such a pain complained of for fifteen, sixteen, seventeen, twenty-four, and even thirty years. The more lasting of these pains are, as might be expected, mode- rate in degree : however, a few have continued for years, and yet at times have raged with a vehemence scarcely to be endured. Both sexes are subject to them, but women much oftener than men, and particularly the very young, and the infirm, and the pregnant. The thorax and hypochondria are the parts which most frequently suffer from them ; and though some of these uneasy sensations may arise from internal disorders, yet in many instances there has been no reason to suspect that the lungs, or liver, or any other of the viscera, had the least share in producing them. In most of these patients the pains could not be traced up to any certain cause ; but in several they have apparently arisen from terror and grief, and anxiety, and have unquestionably been recalled and exasperated by some disturbance of mind. In several instances no sort of relief has been obtained from the cold bath, fomentations, liniments with or without tinctura opii, warm plasters, blisters, cupping, vomiting, purging, sudorifics : setons, and even a spontaneous abscess near the part affected has failed of doing good ; Bath, and sea voyages, have proved equally unsuccessful. It is probable that no great hurt is done to the seat of this pain, since it has continued so long without causing any swelling or change of color; and yet I have once or twice known such ill-conditioned biles, and such a tendency to a mortification, follow the use of a blister, as if the part was far from being in a perfectly sound state ; though there were no manifest signs of its being otherwise, except the pain. The means which have the seldomest failed, and have in some cases evi- dently contributed to the cure, are, cold-bathing, small perpetual blis- ters, or (if there be objections to blisters) emplastrum cymini worn for a long time. The most powerful internal medicine is tinctura opii, from ten drops to thirty given at night alone, or as many choose to give it, either in a spoonful of lac ammoniacum, or with a quarter of a grain of emetic tartar. The extract of hemlock has now and then appeared to weaken the cause of these obstinate ails. Cupping has sometimes succeeded ; but all other bleeding, together with emetics and carthartics, have generally proved at least useless. Beside the pains which are either constantly felt, or rage at certain times, there are others which are regularly intermittent, the fits of DOLORES VAGI—DYSENTERIA. 69 which return as periodically as those of an ague : such I have known in the bowels, stomach, breast, loins, arms, and hips, though it be but seldom that these parts suffer in this manner; but the head and face are frequently afflicted with a periodical pain, which by its violence and duration is not the least of the maladies which embitter human life ; of these some account will be found under the article Capitis Dolores intermittentes. CHAPTER XXX. Dolores vagi. Wandering pains are near akin to the rheumatism, but may be distinguished from it by their being accompanied neither with swell- ing, nor any discolouring of the skin. Are they not chiefly suffered by those, whose muscular fibres have been weakened, strained, or stiffened, by long illnesses, profuse bleedings, bruises, irregular living, hard working, or the advances of age ? They usually continue for many years without other ill consequences than becoming gradually a little more troublesome ; but, in a very few, the parts principally affected have their power of motion more and more lessened, till at last it be quite lost. Time, and warm bathing, and flannel, may con- tribute a little to the cure, or relief, or however to checking the progress of these ails ; and there are scarcely any other helps to be given. CHAPTER XXXI. Dysenteria. The Dysentery is common in camps, but does not often infest those who live in healthy places with the conveniences of life about them, except at certain seasons, when it becomes epidemical, par- ticularly among children, old women, and infirm men, and it is then fatal to many. The distinguishing symptoms of it are frequent wants of going to stool, with excessive pain, and the voiding without any relief a very little inodorous mucus, often tinged with blood, and sometimes pure blood ; a pain just under the navel, together with a fever, and great loss of appetite, sleep, and strength, and some- times a vomiting. Since this distemper is commonly bred in camps by foul air, and is in some degree contagious (yet I have seldom seen two dysen- teric persons in the same house), too great care cannot be taken in regard to cleanliness and fresh air, both for the sake of the patient and his attendants. The usual methods of treating this malady with which I was acquainted often failed of procuring ease, and of pre- venting its ending fatally in a sphacelus of the bowels. It ap- peared that in a dysentery some hurtful humours had been deposited in the intestines, which "threw them into such disorderly agitations 70 HEBERDKNS commentaries. as to hinder the expulsion of what had offended them. T^ ^l' ness with which the neutral salts (especially the cathartic saltj purge their power of controlling and quieting the irregular motions o bowels, and their aptness to stay upon the stomach withou being vomited up, made me conceive hopes that they would make a valu- able addition to the anti-dysenteric medicines. At first i gave y one dram every six hours, which evidently soothed the painsvery soon, and before it had any effect as a purge. In other cases larger quantities were given, and with the double good effect both of afford- ing present ease, and afterwards of entirely removing, by effectual evacuations, the cause of the disorder. After the danger of the distemper is past, the patient will still be teazed with a tenesmus as long as any soreness or extraordinary tenderness of the rectum remains ; in which case a clyster ot hall a pint of fat mutton broth and twenty drops of tinctura lhebaica scarcely ever fails of proving a cure ; and it is almost the only stage of the illness in which opium is either useful or safe : it it were given in the beginning to quiet the pain before any evacuation had been made, I apprehend it would be very prejudicial. Where this distemper had ended fatally, it has been attended with a hiccup, and a fetid water voided by stool. CHAPTER XXXII. Ebrietas. The effects of hard drinking are, flatulence, loss of appetite, morning sickness, wasting of the flesh and strength, tremblings, pains of the stomach, cough, jaundice, dropsy, forgetfulness and inatten- tion, giddiness, diarrhoea, broken sleep. If remedies be applied in time, and the habit of drinking can be broken, much may be hoped for in restoring the health. It is gene- rally a favourable circumstance to have an illness arise from an ex- ternal cause, rather than from any internal failing. Men of a strong constitution and high health are those who most usually indulge themselves in this excess ; and these circumstances, which betrayed them into their danger, will greatly assist in helping them out. Bath water seems specifically efficacious in curing these complaints, if applied to in time, before the liver and stomach are too deeply hurt. Nor is Bath only a remedy against the mischief which has been already done ; but it is also singularly useful in preventing a relapse, by enabling the patients to correct the habit of drinking: for the nature of this water is so friendly in warming and comforting the stomach, as to relieve all that coldness and anxiety which almost irresistibly force a hard drinker to fly to strong liquors for ease under these insufferable sensations. Warm aperient medicines occasion- ally used so as to prevent costiveness, if there be a disposition that way, and bitters, are the whole of what is further necessary to esta- blish the health. EPILEPSIA. 71 CHAPTER XXXIII. Epilepsia. The epilepsy may be called the reproach of physicians as well as gout; for it was well known before the writing of the most ancient medical books, and yet no certain method of cure has been discovered. The number of remedies, which are to be found for it in books and vulgar tradition, afford a strong presumption that we have no effectual one. The difficulty of curing this disease, either by the cautious prac- tice of such who have a character to lose, or the more hazardous attempts of men who have a character to get, is sufficiently evident from its having remained uncured in some who were unabled by their wealth and power, and prompted by their credulity, impatience, or despair, to try all sorts of means for its removal. The good sense of the world has done more than medicine towards mitigating this great evil, by lessening the imaginary part of it: for it is now gene- rally considered in the same light with any other distemper, without adding to its malignity by the workings of fancy or superstition. It is no longer believed to be the immediate effect ot some demon s malice ; nor is it regarded enough to let it dissolve public councils and to put a stop to all business ; neither is it detested with that degree of horror by the acquaintance and friends, which must have shocked the miserable patient more than the cruellest attack of the disease.* , . , , . The fit makes the patient fall down senseless ; and without his will or consciousness presently every muscle is put in action, as if all the powers of the body were exerted to free itself from some great violence. In these strong and universal convulsions, the urine, ex- crements, and seed, are sometimes forced away, and the mouth is covered with foam, which will be bloody, when the tongue has been bitten, as it often is in the agony. This wretched condition affords a picture of the greatest misery and distress even to a stranger; to the friends and relations the horror of such a sight is much greater ; but happily the patients themselves know nothing during the fit ot what the body is enduring. . Many suffer these attacks without the least previous notice ; others are sensible of their approach; and the shock which this foreboding occasions is compensated by their being able to secure themselves from some of the mischiefs of a sudden unforeseen fall. It is not unusual to have a little warning of some of the first fits, and afterwards to have them come on without any previous sign. The more common symp- * Among the ancients, when any one happened to be seized with an epileptic fit those who were present used to spit, and sometimes into their own bosoms; eitner to.snow their abomination, or to avert the omen from themselves. Plautus calls h,s distemper .U„rbus qui .putatur. Captiv. act. in., seen. iv. v. 18, and from what follows, it seems as if they used to spit upon the epileptics as a charm to relieve the convulsions, hum morbummihi esse.ut qui me opus sit insputarier, ver. 21. .Mulfos tste morbus mace. rat, quibus in,p«tavi saluti fait. v. 22. Hence it has been conjectured, that fetPauI » thonun thefiesh, 2 Uor xii. 7. and infirmity ofthefiesh, Gal. v. lo. and ^«™£ thefiesh, ver. 14, might be the epilepsy, and that the word .£,tW*t. is used liter- ally, and not in a metaphorical sense. 72 HEBERDEN'S commentaries. toms which are the remoter forerunners of a fit, are a general restless- ness and uneasiness, a headache, vertigo, and other disagreeable feels in the head, disorders of the stomach, and sleepiness ; these will in many persons hang upon them for two or three days before they fall. The most usual sensations immediately before the fit are a slight de- lirium, which will sometimes continue three or four hours, and a vapour rising up out of the stomach to the head, which in some few affects their palates and nostrils like musk. The less common warnings of the approach of the falling sickness are pains in the bowels, numbness of the hands and arms, a peculiar sensation in some of the extremities gradually diffusing itself all over the body, dimness of sight, a falter- ing, and difficulty, or a total loss of speech, a hiccup, a vomiting and purging, a pain in the back, a coldness of the extremities, a great defluxion of phlegm, a blackness of the face, and shortness of breath; lastly, a tendency to fainting will sometimes be followed by a fit, and sometimes the fit will seem to rise no higher than this, and the patient will escape for that time with feeling no more of it than this half fainting, joined perhaps with a forgetfulness or delirium for a few minutes. These are the shortest fits of all; the more common ones will last from a quarter of an hour to three hours ; and in more extra- ordinary cases the patient will lie senseless for two or three days, having during all this time frequent accesses of convulsions or fits. Giddiness, and dark spots dancing before the eyes, are the constant attendants of some epilepsies. All possible varieties are to be found in the returns of this dis- temper : many will have several of the slighter fits every day, or one in a day, or one in a week, or every month, or only two or three in a year. The epilepsy has lain dormant for thirteen years, and then returned worse and oftener ; in others the respite has been still much longer, though with such threatenings of a relapse, as to put it out of all doubt that the cause still remained. After the con- vulsions have ceased, and the patient begins to come to himself, he generally falls into a sound sleep, for one, or two, or even six hours. It is obvious to suppose that this sleep must prove a relief after the fatigue of the convulsions ; and I never knew but one instance in which it was found so detrimental, that the patient requested al- ways to be roused from it, as he could never indulge it without being the worse. It must be owned that sleep seems to favour the returns of these fits, just as it aggravates all the distempers attributed to the nerves ; the first attacks of the epilepsy being most usually in the night, just after the first sleep. Some epileptics feel themselves so little hurt or altered by a fit, that, knowing nothing of what passes during the time of it, they can hardly be persuaded that they have had one. Others after they have come to themselves have felt a heaviness and numbness for three hours, or a headache, a sickness and vomiting, a languor and dulness, or have not perfectly recovered their understanding and memory for two or three days: and these are the immediate effects of single fits. The more distant ones of repeated fits are, forgetful- ness, stupidity, childishness, and a general debility of the body or EPILEPSIA. 73 a palsy of some parts, or an apoplexy. These consequences appear very soon in some, while others continue a long time unhurt by these violent shocks ; so that some who began to labour under this malady very early in life, and had experienced many returns of it, have yet lived to be promoted to some high offices in the state, merely on account of their extraordinary abilities. Julius Ca?sar is well known to have been a remarkable instance of this kind. Both sexes, and every age, are liable to this illness; children are much more so than adults, and much more easily get rid of it. One would likewise expect that the weaker sex would, on account of their weakness, be greater sufferers by epilepsies ; but it has ap- peared to me, that though boys and girls be equally subject to epi- leptic convulsions, yet fewer women are afflicted with them than men. Convulsions are so common in children, from the day of their birth to their third or fourth year, as to make it probable that they may be occasioned by a variety of transient causes, such as worms, accidental indigestions, griping pains of the bowels, and many other sharp and sudden pains ; there is therefore always ground to hope that a child's convulsions may not proceed from the same obstinate cause from which epilepsies arise in adults ; and ac- cordingly many children under four or five years of age have had a few such fits, who have never afterwards experienced a return. The true epilepsy most usually shows itself in childhood or youth ; but there is hardly any time of life, from the first day of it to extreme old age, at which it has not been known to make its first appear- ance. I have noted several who have begun to be epileptic at almost every year between twenty and fifty; a few have fallen into it at sixty; and I saw one whose first attack was.in the seventy-fifth year of his life, and from that time he was often visited with it for at least six or seven years, and probably as long as he lived. It has been an old observation among physicians, that epilepsies beginning in childhood often terminate about the year of puberty ; which has by no means been verified by any experience which has fallen in ray way. On the contrary, this malady has appeared to me often to come on at that time of life, but I have not remarked one instance of its yielding in either sex to the change made by pu- berty. Wherever it has lasted beyond the fifth or sixth year, it has generally proved a tedious distemper, and reached it beyond the beginning of maturity. If I could therefore suppose that in forty years practice a sufficient number of epilepsies might occur upon which to form a judgment of this aphorism, I should be inclined to think that it was founded on theory, or in the hopes of the physician, rather than in fact. As there is no age at which this great affliction does not come on, so there is hardly any at which it has not finally left the patient.* But it must be owned that it is doubtful whether * IS'icolaus Leonicenus a cunabulis ipsis ad trigesimum annum morbo comitiali adeo la- borabat, ut pertaesus vitae pene sibi manus affer;et : sed post trigesimum annum plane eo malo defunctus, omnibus membn r.im ac sensuum officiis integer, nulla morbi suspi- cions ad quartum etnoiiatje^iinuin annum pervcnit—Jos. Seal. ep. 19. 10 74 HEBERDEN'S COMMENTARIES. nature has not had more share in most cures than medicine, because there is none which has not failed so often, that we cannot be con- fident of its having much merit where it has appeared to succeed. The epilepsy is in some degree hereditary; yet as there are seve- ral examples of its being cured, or spontaneously ceasing, in those whom it had frequently attacked, there is a stronger reason to hope that its powers may be often spent before it reaches the children; and it is found in fact, that many pass their whole lives untainted with this part of the constitution of their parents. In the beginning of the epileptic fit care should be taken to loosen any bandage which might be about the neck ; for this part is apt to swell, and without this precaution might endanger suffocation: the patient should be placed upon a couch, or bed, and watched that he may not fall off, and that he may not throw his legs or arms about in such a manner as to hurt himself. All further officiousness will be prejudicial. To force liquids into the mouth, to hold pungent salts to the nose, to rub the temples, and to force open the hands, is certainly useless, and not quite innocent. To open a vein upon account of the fit is still worse, being a needless waste of blood, which may weaken the patient, but not the disease. The interval of the fits is the only proper time in which any remedies should be employed ; and in such cases as this, where the experience of man- kind has not yet discovered any upon which we can have much de- pendence, there is the most good to be done by finding out the weak part of the patient's constitution, and directing such means as will keep him in the best general health, that he may have every assistance from the powers of life ; for they are so formed, that they are always ready to exert themselves in weakening and removing whatever distresses them; and the stronger they are, the more vi- gorous and successful will their efforts be. No simple has had a greater reputation as an anti-epileptic than the wild valerian root, and it may have been beneficial in some cases; but one ounce, and even fifteen drams, have been given every day with little or no advantage. The gout has come on with- out affording any relief, nor can I say much in favour of blisters, issues, setons, the cold bath, and chalybeate waters, except where they have been useful to the general health. Quicksilver I have known used both inwardly and outwardly; and if it have seemed to do good in one case, it has certainly been useless in another. Two persons have imputed their cure to a total abstinence from all animal food ; but the same abstemious diet has failed in a third. Five ounces of a very strong infusion of wild valerian root, with one dram of musk, given as a clyster every eight hours for three days in a desperate case, had the credit, and perhaps justly, of saving the life of one who had lain senseless, with frequent returns of convulsions, for two or three days. Worms in children or dis- ordered bowels, have occasioned convulsive fits ; and gentle purga- tives will generally cure them, by removing the cause : but purges should always be avoided in a just epilepsy, because the causes of ERYSIPELAS. 75 it will be aggravated by purging. I knew a girl whose fits always came on just after her having a stool. Vomits I have known to be equally hurtful, and likewise bleeding. Sleep unquestionably dis- poses a fit to come on, and a too great indulgence in this article may probably contribute to fix the distemper. All occasions of terror should carefully be avoided ; for terror will not only bring on a fit, but has been the original cause of the distemper. A life of de- bauchery, and particularly an intemperate use of women, has a pe- culiar tendency to produce and strengthen this evil. My expe- rience has furnished me with so little to say concerning the nume- rous anti-epileptic medicines to be found in all the practical writers, that I must let their merit rest on the characters of them which are there to be found. CHAPTER XXXIV. Erysipelas. St. Antony's fire shows itself in a redness of the part, with some degree of swelling, heat, and pain ; and it is frequently beset with small watery blisters. It very rarely appears without a fever, the usual signs of which precede the appearance upon the skin for one, two, or three days. The genuine erysipelas is oftenest seen in the face, head, neck, and shoulders ; yet many inflammations which are the forerunners of a suppuration, or sphacelus, in other parts, par- ticularly the legs, have an erysipelatous appearance, and are called by that name. . This disorder begins with a small red spot in one of the parts just mentioned, which gradually extends itself, and keeps moving from one part to another. The skin is sometimes so deeply hurt, as to have an ill-conditioned ulcer formed, which cannot be healed without much time and care. The little vesicles, if they be nume- rous, will, upon breaking, make the part so sore as to require some soft liniment spread upon linen, to defend it from the rubbing of the clothes. Except in these two cases, it is better not to make use of external application to the parts affected. The height of the fever, which is almost always joined with this disorder, is much greater than mio-ht be expected from the quantity and degree of inflamma- tion, ami not seldom rises to light-headedness, and sometimes is fatal; where this happens, the erysipelatous part becomes pale, and the distemper is said to be struck in. Some constitutions seem par- ticularly subject to this illness, and have frequent returns of it; and whoever has once suffered it, seems much more liable to have it again. It has visited a person regularly once every year, and some- times twice, for many years. The apparently healthy, and young, are not entirely secure from it; but it is much more common in those who are past the prime of life, and who have begun to find their health a little impaired. Instead of giving vent to any thing which injured the constitution, and carrying it off, St. Antony s fire 76 HEBERDEN'S COMMENTARIES. has appeared to me at least to do no good, and I am inclined to think it does some harm. , . , This distemper seems to partake of the nature of those which are called malignant, more than of the inflammatory ; by which 1 mean, that in general it does not require, nor bear, much evacuation. 1 have seen very dangerous symptoms follow not only bleeding, but even a gentle purge, though given after the patient had begun to recover. Notwithstanding this, the inflammation may sometimes run so high, that it may be proper to take away a little blood, which has been done with success; and I have found a spontaneous bleeding at the nose to be advantageous. In this, as in all other fevers, it is necessary to check whatever troublesome symptoms may arise, by their proper remedies; and besides these, I have only to recom- mend two ounces of a decoction of bark, with thirty drops of tinc- tura opii camphorata, or two drops of tinctura opii, given every six or eight hours. CHAPTER XXXV. Essera, or Mettle-Rash. The nettle-rash is a distemper of the skin, which being attended with no danger, is mentioned but seldom, and slightly in books ; though it be often so extremely troublesome, that physicians might justly have thought it important enough to have told us more of what they had learned from their experience relative to its cure. It has its English name from resembling in its appearance the effect of stinging-nettles upon the skin. Sydenham, in his chapter on the erysipelas, reckons it a species of that disease; and Sennertus and others, describe it under the name of Essera, supposing it to be the same distemper with that which is so called by the Arabian physicians. The little elevations upon the skin in the nettle-rash often appear instanteously, especially if the skin be rubbed, or scratched, and sel- dom stay many hours in the same place, and sometimes not many minutes. There is no part of the body exempt from them. Where many of them rise together, and continue an hour or two, there the parts affected are often considerably swelled ; which particularly happens in the face, arms, and hands. These eruptions will continue to infest the skin, sometimes in one place, and sometimes in another, for one or two hours at a time, two or three times every day, or per- haps for the greatest part of the twenty-four hours. In some persons they last only a few days; in others many months. I have known several complain of them for two years with very short intervals and for seven, or even ten years. Males and females are equally liable to the essera, and I have ob- served it in all ages, from childhood to decrepit old age. Constitutions tainted with strumous, or harassed with rheumatic and hysteric com- plaints, or broken down with intemperance, palsies, and age, have all been, as far as I could judge, equally fitted for this disorder ; but ESSERA, OR NETTLE-RASH. 77 not more so than the soundest state of health, in the vigour of life, to which all other complaints were unknown. If some of the sufferers by this eruption have found themselves well whilst it appeared, and infested with pains of the head and stomach, and languors, upon its disappearing, others have complained of as much languor, and equal pains of the stomach, during the time of its appearance ; but far the greatest number experience no other evil from it besides the intolerable anguish arising from the itching, which will sometimes make them fall away, by breaking their rest, and is often so tormenting as to make them almost weary of their lives. The external use of cantharides has been known to occasion this ail in several persons, and in some the internal use of the wild valerian root; but all who are affected with it find the itching and little emi- nences hardly ever fail to be brought on by any degree of scratching or rubbing the skin. The seasons of the year have no constant effect either in alleviating or exasperating the disorder ; and the same may be said of cold and heat, and particularly of the heat of the bed, which appears to make some much better, and others much worse. Sea-bathing has seemed to occasion it in some, and to relieve it in others, but is perhaps in reality innocent and useless in all, as it certainly has been in several, as well as warm bathing, though conti- nued for an unusual length of time. Mercurial and sulphureous oint- ments have been found ineffectual in curing it; and the powder, in- fusions, and decoctions of white hellebore root, in ointments and lotions, have only for a short time changed the itching into smarting. Oil, vinegar, and spirit of wine, applied to the skin, will sometimes mitigate the itching, and afford a little present relief. The appearance of this eruption was before said to resemble the sting of a nettle ; but, together with such little risings in the skin, there are sometimes long wheals as if the part had been struck with a whip. Whatever be the shape of these eminences, they always appear solid, without having any cavity or head containing either water or any other liquor ; and this affords a useful mark by which this cutaneous affection is distinguishable from the itch ; for it often happens that the insufferable itching attending this eruption provokes the patient to scratch the parts so violently, as to rub off a small part of the cuticle on the top of these little tumours ; a little scab suc- ceeds, and when the swelling has gone down, there is left an appear- ance hardly to be distinguished from the itch, but by the circumstance just now mentioned. It has been this exact resemblance which has occasioned the application of sulphureous and mercurial ointments in many persons whom I have seen without producing either any good or bad effect. The essera further differs from the itch in not being infectious ; for though I have once suspected that a husband had catched it from his wife, yet my suspicion was probably not well founded in this instance, because in many others I have known that this complaint showed no signs of being communicable by contagion. I never saw a reason to suppose it had occasioned any such vicious- ness of the humours, as greatly to require, or to be much the better for 78 HEBERDEN'S COMMENTARIES. internal alterative remedies : and if the itching could be certainly and expeditiously allayed, we might spare ourselves the pains of looking out for any other method of cure. CHAPTER XXXVI. Expergefacti cum Clamore et Terrore. To wake in a violent hurry and agitation, and with loud exclama- tions, is a symptom sometimes observed in the gout, in palsies, and in hysteric complaints : it is a very common attendant upon pains of the bowels, worms, and convulsive fits in children ; and when they have started out of their sleep in this manner, they have been above an hour before they have perfectly come to themselves. CHAPTER XXXVII. Febris. A fever, or general languidness with a quick pulse, is sometimes an attendant upon other disorders, and will retreat in proportion as they are mitigated by their proper remedies. When it is itself the only distemper, it is still so various in its nature, that very different methods of cure must be employed for different fevers; and some part of the treatment must be learned from knowing the patient's age, and constitution, and manner of living, as well as from a due attention to the season of the year and the peculiar nature of the reigning disease. Where the fever is evidently inflammatory, as in the inflamed sore throat, peripneumonies, pleurisies, and inflammations of the bowels, there no one can doubt of the necessity of bleeding ; and repeated bleedings are often required. The jail-fever, and others which re- semble it, seldom appear to stand in need of bleeding ; but it is often of great importance in the beginning- of these fevers to clear the stomach and bowels, which is pointed out by the sickness which at that time teazes the patient. This may very properly be done by one scruple of ipecacuanha, joined with one grain of emetic tartar, which, beside vomiting, will generally occasion a few stools. The sickness is usually so perfectly removed by one dose of this medicine, that a second is very rarely wanted. A headache is a very distressing symp- tom in the beginning of fevers, for which a blister between the shoulders is an almost certain remedy. In the inflamed sore throat, pleurisies, and peripneumonies, blisters are likewise of great use in abating (perhaps by diverting) the inflammation, and in all stages of low fevers, where they act as cordials, and stimulate the powers of life to exert themselves, and to shake off the languor with which they are oppressed. The strangury which they are apt to occasion is cer- tainly cured by a clyster made of water and oil, each two ounces and fifteen drops or more of tinctura opii. In the progress of the FEBRIS. 79 illness, if a purging should come on, the helps mentioned under the article of diarrhoea, must be employed to check it. The contrary state of too great costiveness will be best removed by a clyster of half an ounce of salt, and twelve ounces of water, with two ounces of oil. Restlessness and want of sleep, will often yield to fomenting the head and feet frequently with flannels wrung out of hot water; or two or three drops of tinctura Thebaica may be given every six hours. Heat, and thirst, may be allayed with lemonade, or toast and water. Languor, and excessive lowness, may safely be treated with wine or cider mixed with water, or a spoonful of the camphor julep. Hiccups, and convulsive twitchings, and agitations, have ap- peared to be relieved by frequently taking a spoonful of the musk julep ; but though musk may have some virtue in quieting spasms, and camphor has in some cases procured sleep, yet their effects are neither great, nor constant. I have seen one scruple of camphor given every six hours, and, together with this, one scruple of musk as often in the intermediate hours: they were both of them borne well by the stomach, but had no perceivable effect in abating the convulsive catchings, or composing the patient to rest. While the sick person is in his senses, his own inclination, and strength, will best determine whether he should sit up, or keep his bed, even in the eruptive fevers, as well as in all others. A specific in continual fevers is, I fear, still one of the desiderata in physic, though it has been much sought after, particularly among the preparations of antimony. In the beginning of fevers, the safe antimonial emetics and cathartics are unquestionably useful; but I have never yet been able to satisfy myself that they do more good than would be done by any other equally strong purges and vomits. Many judicious physicians are persuaded that, in the succeeding stages of a fever, antimonial medicines, given in such a dose as just not to vomit or purge, are efficacious in abating the fever, either by bringing on a sweat, or by some specific power. In deference to their judgment, I have directed four grains of emetic tartar to be dissolved in four ounces of some simple distilled water, of which solution I have given two drams, which contain a quarter of a grain, mixed with three spoonfuls of water, every six hours. This quantity is as much as an adult can usually bear without being sick ; and where it is more than the stomach can be easy with, the draught may be divided into two parts, to be taken at the distance of half an hour from one another, instead of the whole being taken at once. Of this medicine I have had considerable experience ; but not enough to convince me that antimony possesses any specific virtue of curing continual fevers. The Peruvian bark has been much dreaded, except in a clear and perfect intermission ; but the free use which has been made of it, notwithstanding the height of the fever, in mortifications, and in other cases, where a good suppuration was wanted, has taught us, that this dread is as groundless as the many other fears which people have had of this valuable simple ; of which the more we know, the less 80 HEBERDEN'S COMMENTARIES. danger we find of its doing any harm, and the more powers of doing good. Accordingly it has been tried in high continual fevers, in which I am not so sure of its being useful, as I am of its being inno- cent, not only when two ounces of the decoction have been given every four hours, but when two scruples or a dram of the powdered bark have been directed to be taken as often. In every fever it is of the utmost consequence to keep the air of the patient's chamber as pure as possible. No cordial is so reviving as fresh air; and many persons have been stifled in their own putrid atmosphere by the injudicious, though well meaned, care of their attendants. The English seem to have a very extraordinary dread of a person's catching cold in fevers, and almost all other illnesses ; the reason of which I could never rightly comprehend. The sick do not appear to me to be particularly liable to catching cold ; nor do I know that a cold would be so detrimental, as not to make it worth while to run the risk of it for the sake of enjoying fresh air. I re- member one, who, being delirious at the eruption of the small-pox, was so unmanageable, that by frequently throwing the clothes off, and being frequently naked, he catched a great cold, as appeared by all the common signs of one ; yet I could not observe that it had any iff effect in retarding the maturation, or heightening the fever, or pre- venting his recovery. It is often useful not only to keep the room well ventilated, but likewise to correct the bad air, by pouring vinegar on a red-hot shovel, and making the room full of the acid vapour which arises from it. Very pale urine, unless the patient have drunk a great quantity of small liquors, is a bad sign in fevers, and it is very desirable to see it become thick, and deposit a sediment; but I know no other use of it, than the giving us hope that the distemper is beginning to abate : nor am I aware that any important purpose can be answered by ex- amining the feces ; for I know no state of them which could direct us to employ, or to forbear, any particular method of cure. For the use of observing the pulse in fevers, see the Medical Transactions, vol. ii., art. 2. In the long and dangerous fevers of children, it is very common for them to lose all power of speaking for many days ; but this is no bad sign, and as the fever abates, the voice always returns. Adults, as well as children, are sometimes rendered deaf for a time, without any bad consequence. Concerning the wry-neck of children, see chap, xci., on Spasms. CHAPTER XXXVIII. Febris Intermittens. The fit of an intermittent fever seldom lasts above twenty hours and not often so long. The shivering, and sense of coldness, with which it begins, will continue from half an hour to two hours • then succeed the heat, and restlessness ; and these yield to a sweat the FEBRIS INTERMITTENS. 81 degrees of which, and duration, are very various, according as they are more or less promoted by lying in bed and drinking warm liquors. The fit will be a quotidian, returning every day; or a tertian, and return every other day; and if there be the interval of two days be- tween the fits, it is called a quartan. Much longer intervals have been known ; but these happen so seldom, that they have been dis- tinguished by no name, and are not of any importance to deserve our notice. Besides the common appearances of fever, every fit has been some- times accompanied with other complaints; in some with rheumatic pains ; in several with a light delirium; in others with an eruption of the skin, or colic, or faintings, with a pain and swelling of the testicles, a languidness, and almost paralytic weakness of the limbs. These have regularly come and gone with the fever, and with the cure of that have finally disappeared. It is a question, or rather perhaps it was a question before men knew well how to cure an intermittent, whether they might safely attempt to cure it. For it was supposed to be an effort of the body to relieve itself from some latent seeds of mischief, which would show themselves if the intermittent were cured. Some respectable names in physic have patronised this opinion, and I began to practice with a persuasion of its truth : but every year's experience weakened my belief of this doctrine, and I have long since, by numberless proofs, been convinced of the safety of stopping this fever as soon as possible : nor can I doubt of having observed ill consequences where the fever has been suffered to remain, by delaying to use the effectual means of preventing its returns. The Peruvian bark is the well-known specific, with which Providence has blessed us for the cure of this disorder; and if the first fit has been marked so clearly, as to leave no doubt of its being a genuine intermittent, this remedy should be immediately given in such a manner, as to prevent, if pos- sible, a second. If six drams of powdered bark can be got down, by taking a dram at a time, before the hour of its return, the patient will find the fever at least much weakened, if not entirely removed ; and the same quantity taken four times a day for six days will usually free the patient from all danger of a relapse. But if this medicine be not uncommonly disgustful, there may good arise, but there can be no harm, from his taking it twice a day for ten days longer. This way of using the bark I think is the most to be depended upon; but where the bark in substance cannot be taken, or borne, there two ounces of a strong decoction used as often will generally be successful. The success would be made less uncertain, if there were no objection from the patient's palate, or stomach, to the dissolving in each dose one scruple or half a dram of the extract. Bark is a difficult medi- cine to be got down children's throats, especially in such quantities as would cure their agues. One scruple of the extract, and as much sugar, first mixed with half a spoonful of water, and then with a spoonful and a half of milk, is a form which will disguise its nauseous- ness sufficiently for many children to take it without any unwilling- 11 82 HEBERDEN'S COMMENTARIES. ness. But wherever either in them, or in adults, it cannot be taken or borne in any form upon the stomach, they may still have the benefit of it by having three or four ounces of the decoction with one or two drams of the powder injected at least twice a day as a clyster ; and if this should not readily be retained, ten drops of tincture of opium may be added. It has been proposed to cure an intermittent by keeping the feet immersed in a strong decoction of bark : this I have known tried without success. Cases sometimes occur in which the bark, though properly taken, will not hinder the returns of the fever: this is suspected to be owing to a foulness of the stomach, which hinders the bark from making a due impression upon it; and there- fore an emetic is given, and afterwards the bark is repeated as at first. If it still fail, a scruple of camomile flowers, powdered, may be given in the same manner as the bark, and I have known this method more than once succeed : I have also given in some extraordinary cases two scruples of calamus aromaticus, and have found it more effica- cious than a variety of other means which had been previously di- rected. Sometimes it has been of use to take twenty drops of tinc- ture of opium when the fit is coming on. A quartan ague is far more obstinate than a quotidian, or tertian, and will for a long time elude the power of the bark given in the usual manner, and all other remedies. I have found several of the inveterate quartans yield to a quarter of an ounce of the bark taken just before the coming on of the fit. From a persuasion that the bark is dangerous, if taken before the fever has perfectly subsided, many begin to take it from very uneasy apprehensions, and sometimes will too long delay taking it, to their great detriment. Now the only harm which I believe would follow from taking the bark even in the middle of the fit, is, that it might occasion a sickness, and might harass the patient by being vomited up, and might set him against it; but in my judgment it can never be taken too soon after the fever begins to decline, provided the stomach will bear it. CHAPTER XXXIX. Febris Hectica. A hectic fever is frequently mentioned in the writings of physi- cians, and likewise in common conversation ; but the precise mean- ing of the term hectic has not been well settled, and generally ac- knowledged ; so that probably, by different authors, it is not always used to express the same illness. I understand by it that fever which passes under the name of the irregular intermittent, or symp- tomatic, and what usually attends great suppurations ; of which it may not be useless to give a short description, with some mention of the causes by which it is brought on. This fever very much resembles the true intermittent, from which it must be carefully distinguished ; for their nature is totally different requiring a very different treatment, and the two distempers are ex- tremely unlike in the degree of danger with which they are attended. FEBRIS INTERMITTENS. 83 In the intermittent the fits are longer, and the three stages of cold, and heat, and perspiration, are more exactly defined, and in all the fits continue nearly the same length of time : after which there is a perfect cessation of the fever. But in the clearest remissions of the hectic there is still some quickness of the pulse, so as to beat at least ten strokes more in a minute than it should in a healthy state. The fits also of the hectic vary from one another, seldom continuing to return in the same manner for more than three times together. The shivering is sometimes succeeded immediately by perspiration, with- out any intervening heat ; sometimes it begins with heat, without any preceding cold ; and the patients sometimes experience the usual chillness without any following heat or sweat. The fit therefore of the hectic is usually shorter, but not only because the whole three stages are shorter, but because one of them is often wanted, and sometimes even two. The hectic patient is very little, or not at all relieved by the breaking out of the sweat; but is often as restless and uneasy after he begins to perspire, as he was while he shivered, or burned. All the signs of fever are sometimes found the same after the perspiration is over ; and during their height the chilliness will in some patients return, which is an infallible character of this disorder. Almost all other fevers begin with a sense of cold ; but in them it is never known to return and to last twenty minutes, or half an hour, while the fever seems at its height; which in the hectic will sometimes happen. However, it is not very unusual for the hectic to have two fits, and even three, as exactly resembling one another, as those of a genuine intermittent; but afterwards they never fail to become totally irregular: so that I hardly remember an instance in which the returns continued regular for four successive fits. The hectic in some cases come on so seldom, and is so slight, as scarcely to be perceivable for ten or twelve days ; but in other in- stances, where the primary disorder is very great, the fever will be strongly marked, and will attack the patient several times on the same day, so that the chilliness of a new fit will begin as soon as the perspiration of the former is ended. Several little threatenings of a cold fit have been known to return within a few hours. In a regular intermittent, the urine during the fever is pale, and thick in the intervals ; but its appearance in the hectic is governed by no rules ; so that it will be either clear, or loaded, equally during the fits and in the intervals ; or even muddy in the fever, and clear in its absence ; and will now and then, as in common fevers, be pale during the attack, and muddy afterwards. Beside the usual distress of a fever, the hectic patient is often ha- rassed with pains like those of the rheumatism, which either wander through the whole body, or remain constant and fixed in one part; and, what is rather strange, often at a great distance from the pri- mary malady, and in appearance unconnected with it. These pains have been so great, as to make no small part of the patient's suffer- 84 HEBERDEN'S COMMENTARIES. ings, and to be not tolerable without the assistance of opium, ^h^y are chiefly observable, as far as I can judge, in those whose hectic has been occasioned by ulcers in the external parts, as in cancers ot the face and breast, and in other places open to the outward air. In some few hectic cases it is remarkable that considerable tumours will instantly arise upon the limbs, or body, lasting only for a few hours, without pain, or hardness, or discolouring of the skin. There have been those who when they thought themselves tolera- bly well have suddenly and vehemently been seized with a fever, not unlike an inflammatory one ; and, like that, seeming very soon to bring the life into danger. However, after a few days, the distem- per has abated, and the patients have had hopes of a speedy recovery: but these hopes have not improved upon them ; for though the first commotions have subsided, and but little fever remain, yet this little, being kept up by some deep and dangerous cause, resists all reme- dies, and gradually undermining the health, ends only in death. But this is one of the rarer forms of this malady ; for in the beginning it most usually dissembles its strength, making its approaches so slowly, that the sufferers feel themselves indeed not quite well, but yet for some months hardly think themselves in earnest ill ; for they com- plain only of a slight lassitude, and that their strength and appetite are a little impaired. This state of their health may be judged not very alarming ; but yet if at the same time the pulse be found half as quick again as it should be, there will be great reason for solicitude about the event. There are not many diseases in which an attention to the pulse affords more instruction than it does in this ; yet even here, whoever relies too confidently and entirely upon the state of the pulse, will in some cases find himself misled : for it happens, as well as I can guess, to one among twenty hectic patients, that while all the powers of life are daily declining, with every sign of an in- curable mischief, the artery will to the last minute continue to beat as quietly, and as regularly, as it ought to do in perfect health. Great suppurations in any part of the body will bring on this fever; and it will particularly attend a scirrhous gland, while it is yet very little inflamed, and in the very beginning of the inflammation. It increases in proportion as the gland becomes more inflamed, or ulcer- ous, or more disposed to a gangrene. Glandular diseases are of such a nature, that some patients will linger in them, not only for many months, but even for a few years. When a scirrhous inflammation is in any external part, and obvious to the sight, or touch, or when its seat is in the lungs, or in any of the viscera, whose functions are well known, and cannot be disor- dered without showing manifest signs of the disease, in all such cases we can be at no loss about the cause of the fever. But if an internal part, the uses of which are not clearly known, happen, by being diseased, to bring on hectic symptoms, there the fever which is only symptomatic, may be mistaken for the original and only dis- temper. Lying-in women, on account of the mischief arising from difficult FEBRIS INTERMITTENS. 85 births, are liable to this/ever, and it often proves fatal. The female sex in general, after they have arrived at their fiftieth year, are in some danger of falling into this irregular intermittent: for in that change which their constitution experiences about this time, the glands of the womb, or ovaries, or of the breasts, are apt to become schirrous, and as soon as they begin to inflame, the hectic comes on; and not only these, but all the glandular parts of the abdomen, seem at this time particularly liable to be diseased, and to bring on this, of which we are speaking, as well as all other signs of a ruined consti- tution. The same evils are the portion of hard drinkers, arising from the scirrhous state of the liver in particular, and often of the stomach, and other viscera, which are the well-known effects of an intempe- rate use of wine and spirituous liquors. The slightest wound from a sharp instrument has been the cause of many distressful symptoms, and such as have even proved fatal. For after such an accident, not only the wounded part has been in pain and has swelled, but other parts of the body, and those at a great distance from the wound, have been affected with pain and swelling, and have shown some tendency to suppuration. These symptoms never fail to be joined by the irregularly intermittent fever, which continues as long as any of them remain. The time of their continuance is uncertain : some have been harassed with them for two or three weeks ; and others for as many months ; and, in a few, they have ended only in death. The hectic fever is never less formidable than when it is occasion- ed by a well-conditioned suppuration, in which all the injured parts are resolved into matter so circumstanced as to be readily discharged from the body. Inflammations of scirrhous glands in the breasts, or in the interior parts, sometimes yield to remedies, or to nature, and together with their cure, the fever, which depended upon them, ceases. But these diseased glands much oftener end in cancers and gangrenes ; and the fever continues as long as any life remains. It cannot be supposed that a fever arising from so many different causes, and attended with a great variety of symptoms, should always require, or bear to be treated in the same manner. As the hectic is always occasioned by some other disease, whatever most effectually relieves the primary malady must be the best means of relieving all its natural attendants. WThen the fever has been the consequence of some small wound, a mixture of opium and assafoetida will prove an useful remedy. In almost all other cases, the attention of the physician must be chiefly, if not wholly employed, in removing the urgent symptoms. A cooling regimen will temper the heat, when it is excessive ; the bowels must be kept nearer to a lax than a cos- tive state ; sleep, if wanted, must be procured by opium ; profuse sweats may be moderated by a decoction of bark and elixir of vitriol; beside which, the greatest care must be taken that the air and food, and exercise, may be all such, as will be most conducive to putting the body into the" best general health. After doing this, the whole 86 HEBERDHVS COMMENTARIES. hope must be placed in that power, with which all a"im^ *"• of dowed, not only of preserving themselves in health, but 1jk^some correcting many deviations from their natural state. An in " _ happy constitutions this power has been known to exert itseii - cessfully, in cases that have appeared all but desperate. * 01-so patients have recovered from this fever, after there had appeared very great signs of its arising from some viscus incurably diseased, wne e every assistance from medicine had been tried in vain, and where the strength and flesh were so exhausted, as to leave no hopes ot any help from nature. In this deplorable state, a swelling has been known to arise, which, though not far from the seat of the primary disorder, yet could not be found to have any immediate communica- tion with it. This tumour has at length suppurated, in consequence of which the pulse has grown calmer, some degree of appetite has returned, and all appearances of distemper have gradually lessened, till the strength and health were perfectly restored. What in some very few instances I had observed nature thus to effect, I have en- deavoured to imitate, by applying a blister, or by opening an issue, or seton, near the apparent seat of the internal mischief; but the success has not answered my expectations. Not many years ago, in some fortunate recoveries from mortifica- tions, the Peruvian bark had been prescribed, and had the credit of the cure: since which time it has been very generally used by prac- titioners in all tendencies to gangrenes, and where suppurations had not proceeded in a kindly manner. There is every reason to believe, that it may safely be employed in such cases; and no other remedy is known, which has any pretence to rival it for these purposes. Be- sides, as the hectic fever is so very like an intermittent, even where there was no suspicion of any gangrene or ulcer, the desires of the sick, or of their friends, for trying the bark, have been too importu- nate to be controlled ; and physicians have sometimes prescribed it from their own judgment. But it has greatly disappointed all ex- pectations of benefit to hectic patients ; for it seems to have no effi- cacy, where there is no ulcer ; and indeed it has so often been use- less in mortifications, that there may be some doubt, whether in the prosperous cases the cure were not owing to other causes. But though I dare not be confident that the Peruvian bark has any extraordinary virtues in stopping the progress of mortifications ; yet I can have no doubt that it may safely be used: for neither in these cases, nor in any other, have I ever had reason to suspect its doing harm, unless it can be said to do so when it occasions a sickness or diarrhoea, where the stomach happens to be weak, or the dose has been too great, or where it has been taken in hard boluses, which were not readily dissolved in the stomach: and I remember to have heard Sir Edward Hulse say the same, who had for above forty years been giving as much of it as any physician in England, and probably much more than any one had given in all the other countries of Eu- rope. Experience every day more and more confirms this testimony in favour of the bark: and hence it must have happened, that the FISTULA ANI. 87 quantity of it used in England for the last ten years, is ten times greater than it was in the same length of time in the beginning of the eighteenth century. It is evident, therefore, that the more we know of this noble simple, the less reason we find for those suspicions with which it was at first calumniated ; so that it affords some exception to the general rule, ubi virtus, ibi virus. Yet we are told, that many physicians are still afraid of ever giving it in the beginning of an in- termittent ; and some are afraid of ever curing it at all with this re- medy. They may perhaps adhere to the doctrine (which I believe is founded in error,) that an intermittent is an effort of nature, by which the constitution frees itself from many hurtful humours, and from the rudiments of many impending diseases; and consequently where these friendly exertions are checked, those dangerous maladies will fall upon the internal parts, terminating in fatal dropsies. I sus- pect these groundless fears have had their origin from those fevers, which were falsely judged to be intermittent, when in reality they were hectic ; and that the obstructions in the abdominal viscera were not owing to the bark, but were the original cause of the illness. In all chronical disorders which yield to no other remedies, it is usual for the sick to be urged by their own hopes, and by th&advice of their friends, to make trial of the Bath waters. Now the incon- veniences of travelling and of missing the comforts of their own houses, must occasion some additional sufferings to the sick; and for these the hectic patients can have no just hopes of having any amends made them by going to Bath : on the contrary, those waters would not fail, by heightening the fever, to aggravate all their complaints, and to hasten their death. CHAPTER XL. Fistula Ani. Fistula ani, scirrhi, and ulcers of the rectum, are often attended with griping pains, tenesmus, a want and difficulty of making water, a difficulty of retaining the stools, mucous and bloody stools, the stools always loose, or not round but flatted, shiverings, a swelling, and sometimes a gangrene of the testicles, flying pains, and some- times very acute and fixed ones in a distant part of the limbs. The ulcers which are formed in the rectum near the sphincter ani are often neglected, upon a supposition that they are only piles; though the pain of the previous inflammation be far greater, and much more increased by coughing and sneezing. Even after the suppuration has been made, and the ulcer is broken, the discharge from it, if not great, will still be undistinguished from the piles; for a moisture has for a considerable time continued to ooze out from them, where experienced surgeons upon examination have not been able to find any ulcer. However, where the pain is excessive, or there is any purulent discharge, the opinion of a surgeon is indispen- sably necessary ; for, if there be an inflammation or ulcer, the whole 88 HEBERDEN'S commentaries. care of it belongs to him, and the sooner he is employed, the better it will be for the patient. A timely use of the proper means may hinder the forming of deep sinuses, which cannot perhaps ever be brought to a healing condition, or not without a much more paintul operation than the cure would at first have cost. Fistulous sores of the rectum will remain unhealed, and keep dis- charging like a fontanel for a long time : one has done so lor more than thirty years. In some constitutions a previous unhealthiness may make a deposit upon the intestine ; in others perhaps a neglected ulcer, arising from slight, and merely local causes, may in time taint the whole body. Whether then we consider the fistula as the cause, or as the effect, it is certain that a bad state of health is often joined with a fistula ani, and the mischief, after the cure of the ulcer, has many times fallen upon other parts, and particularly the lungs, and has brought on asthmas, spittings of blood, and consumptions. For this reason it is a common, and appears to be a reasonable practice, to make an artificial discharge by an issue, as soon as the wound is healed, in order to drain off any of those diseased humours, which at first occasioned the mischief, or were afterwards occasioned by it; and to recommend such a regimen as a consumption requires. CHAPTER XLI. Fluor Albus. The fluor albus is a weakness which has been known to incom- mode females in every year of their lives, from the first to extreme old age ; but it is very rarely observed in children, and most usually is first heard of about the time of puberty. This discharge, though generally white, as the name imports, and thin, yet has sometimes had almost a jelly-like consistence, and not unfrequently a tinge of yellow : in a few women it has been greenish, with an offensive smell. The sharpness of the humour frets the parts, if not duly washed, so as to occasion heat, itching, or soreness, and the urine of course will occasion a little smarting. It is evident from this account, that great attention is necessary to distinguish this dis- order from a Venereal infection, wherever there is a possibility of its having been communicated. When a woman has lived entirely free from the fluor albus, or has had it only in a slight degree, and all at once, upon cohabiting with a man finds a great pain in making water, and the discharge suddenly appear, or greatly increased, with a deep yellow or greenish hue, there will be strong reason to suspect an in- fection. It unluckily happens, that a woman soon after marriage is particularly subject to this disorder, especially if she be of a weakly make, which has often created great uneasiness, and many disagree- able suspicions : in these circumstances much caution is necessary in passing judgment upon the nature of the discharge. If the colour of it remain white, or at the deepest is only of a faint yellow, and the smarting of the urine little or none, there will be no reason to be- FLUOR ALBUS. 89 lieve it more than a simple weakness, even though the person should never have experienced any thing of it before. The most common cause of this malady is frequent miscarriages, or lyings-in. It has made its first appearance, o; been increased, in many women during a state of pregnancy ; yet I have met with one, who thought herself freer from it at that time. This flux has in many instances returned every month instead of the menstrual one ; or has continued without ceasing during an obstruction of the menses, and is not unusual in elderly women just after their final disappearance. A too profuse menstrual evacuation, and this, will often harass the same subject, both of them being perhaps owing to too great weak- ness. Too violent exercise, the lifting or carrying of too great weights, intemperate venery, great disturbances of mind, and a weakly or strumous habit of body, have been no uncommon causes. Whatever may have been its origin, the patient is sure to find it ac- companied with a great pain of the loins, and this is not the least part of their sufferings. Such a constant drain must probably in some measure lower the health and strength, but it is not easy to point out any other ill consequences. We meet with many, women who have had it for a great part of their lives, and have not been hindered by it from bearing healthy children. Where a weakness of the whole habit, or a partial one of the glands which supply this humour, are judged to be the only causes, the remedies must be calculated to make the whole body more ro- bust, or to strengthen the parts concerned. A powder made of olibanum and Seville orange peel, each ten grains, with five grains of oak bark, taken twice a day,.and washed down with an infusion of Peruvian bark, has had a good effect; and so has a decoction of oak bark, in the proportion of one ounce to a quart of water, in- jected into the vagina night and morning. These together with cold bathing have proved the most powerful helps. But this disorder, though not dangerous, is often very obstinate from the length of time it has lasted, or from some constitutional weakness; and will only admit of being checked, and lessened, but never will be en- tirely cured. Besides, in strumous habits it is not merely a weak- ness, but a drain by which part of the noxious humours is carried off: this creates an additional difficulty of curing it, and an impropriety of attempting it merely by strengthening remedies. Where such have been used in these cases, and have either stopped or consider- ably lessened the discharge, the patients have presently complained of pains of the stomach, and have found a general illness, by which they were far more hurt than by the former flux. To such patients injections must not be prescribed ; instead of which, together with internal strengthening medicines, they should twice a week take some gentle purging waters, or some of the neutral salts dissolved either fn water, or in an infusion of Peruvian bark. Bristol water has the reputation of being useful in this complaint, which I have no reason to think it deserves. I have known cases in which saccharum Saturni had been used without effecting a cure ; but if it had been 12 90 HEBERDEN'S commentaries. ever so successful, the consequences of taking such a dangerous sub- stance would have been far more prejudicial than the distemper. Excruciating pains of the womb and hips and thighs, which be- long to an ulcer or cancer of the womb, together with the sanious and bloody appearance of the gleet, will generally be sufficient to distinguish it from the fluor albus. CHAPTER XLII. Gonorrhoea Mitts. A gleet in men resembles the fluor albus both in its nature and cure ; so that very little needs here be added to what has been al- ready said under the last article. Such a weakness is far less com- mon in men, than in women ; being hardly ever known in them, without being owing to Venereal diseases. However, I have been a witness to two or three cases, in which a blow had brought on a copious discoloured flux, exactly resembling that from a Venereal infection, except that it went off spontaneously in a few days. Injections into the urethra should be used sparingly, if at all, if I am not mistaken in supposing that the free use of them has been the cause of many strictures, as they are called, of the urethra, at- tended with an extreme difficulty and excessive pain in making water, which too often prove an incurable torment, and end in a fatal suppression of urine, or a mortification. An abstinence from the causes which brought on the gleet, seldom fails to cure it, or to reduce it so far as never to do any material injury to the health. Yet many timid minds suffer more from their apprehensions of the con- sequences of this complaint than of any other ; and interested peo- ple have endeavoured to aggravate those fears, in order to make an advantage of them by the sale of their silly books and insignificant medicines. CHAPTER XLIII. Graviditas. Most of the complaints incident to breeding women are to be cured only by their delivery. Women readily conceive a little be- fore the time of the menstrual flux. Do they more readily at that time,'than at any other ? J A healthy woman in the fifth month of pregnancy began to per- ceive a moisture oozing from the nipples, which continued till two days before her delivery ; the breasts were then quite dry for six days, but on the fourth day after the delivery they were filled with milk. I have been told by two married men, that their wives were free from all Venereal appetite ; yet they both of them had been preg- nant, and had borne several children. y ° HiEMORRHOIDES. 91 Pregnancy is very commonly accompanied with sickness and with the heartburn : where these two complaints have been excessive, after a variety of means had been used in vain, the sickness has been cured by rubbing in the anodyne balsam upon the region of the stomach, and the heartburn by repeated doses of elixir of vitriol. A woman not suspecting her condition, went on bathing fre- quently for the first months of her being with child, and drinking the sea water so as to be purged two or three times every day ; and this was the only time she ever escaped a sickness, which she had suf- fered in an uncommon degree with all her other children. The juice of oranges and lemons, and plenty of fruit, have also proved remedies for the same sickness. A violent uterine discharge of blood has continued for six weeks about the sixth month, without occasioning a miscarriage. I knew one, who never ceased to have regular returns of the menstrua during four pregnancies, quite to the time of her delivery. Consumptive women readily conceive, and during their preg- nancy the progress of the consumption seems to be suspended; but as soon as they are delivered, it begins to attack them with redoubled strength ; the usual symptoms come on, or increase with great rapidity, and they very soon sink under their dis- temper. A difficulty, or total suppression of urine, is sometimes occa- sioned by the weight of the womb pressing upon the urethra, which can only be relieved by the catheter. After a suppression for three days, upon introducing a catheter, five pints of water came away. Large blisters applied to some pregnant women, who were peculiarly liable to the strangury, have occasioned it in so violent a degree, as to endanger a miscarriage. CHAPTER XLIV. Hcemorrhoides. The veins towards the extremity of the rectum are liable to be surcharged with blood, in consequence of which they sometimes burst, and bleed without any pain, like the veins in the inside of the nostrils ; at other times they swell without bursting, to a con- siderable size both within and without, and are in great pain even after they have begun to bleed. This discharge of blood is com- monly reputed to be wholesome, and the checking of it by for- cible means, it is supposed, will occasion headaches, giddiness, pains of the stomach, and even lay the foundation of a broken state of health, some great mischief being deposited upon the vitals by that blood, which should have found an outlet through the hemorrhoidal vessels. Now, we know very well, that in a per- fectly healthy state there is no want of this evacuation, and wher- ever it happens, it may perhaps more justly be called a symptom, than a remedy of any disease. 92 HEBERDEVS COMMENTARIES. In many people the veins of the rectum bleed from as trl^ia] causes as those of the nostrils, and there is no harm m negiecung such a hemorrhage. There are several diseases of th%a°d0™inal viscera, which put some obstruction to the free passage of the biooa through them, and this may probably occasion a breach in the lowesx part; so, we find that in affections of the liver, hemorrhoidal bleed- ings are very common, and possibly may give some little reliel at the time, but are not likely to contribute at all to the cure, tfowel disorders too often prove fatal; and if the bleeding of the piles should have been checked by any applications, the mischief may falsely be attributed to the want of that evacuation. I have heard a few persons say, that a headache, an asthma, a giddiness, a red- ness of the face, and a pain of the stomach, had been prevented, or removed, by bleeding piles. There is some difficulty in determin- ing whether they were mistaken, which might easily happen; but certainly the benefits of the piles are by no means so frequent, and so evident, as to make any one either wish for them, or be pleased with having them. There is however no very great use in deciding the question of the wholesomeness of the piles, the bleeding being seldom so excessive as to threaten either present danger, or future mischief. Yet in rare cases I have known so great a flow of blood from them every day for a month together, that it unquestionably weakened the patient. But even in this state of the piles, it is hardly ever found necessary to go beyond the use of half a pint of the decoction of the bark taken at three or four times every day, which perhaps acts less as a styptic, than by obviating the ill effects of such profuse bleedings. The piles spare neither sex; they have begun as early as at the age of five years ; but they very seldom molest children, and may rather be considered as the disorder of adults. Women during the state of pregnancy, and just after the menses have finally left them, are peculiarly subject to the piles : at all other times they are less troubled with them than men. The piles are habitual in many constitutions, and have continued through life with no great interruption. Both costiveness and purging will irritate them. They will not only bleed at every stool, but a serous moisture will constantly ooze out spontaneously without any ulcer. The blood does not appear intimately mixed with the excrement, but lying upon it. The pain is greatly increased by going to stool, and will last for some hours after. A heat of urine, a sickness, and pain of the loins, are sometimes, though rarely, com- plained of together with the piles. Aloes is carefully avoided in this disorder, as a purge which particularly irritates the rectum, and not without some little reason ; but it appears to me, that it has not such an effect so generally, and so strongly, as is commonly ima- gined ; and it will therefore often disappoint those who, having a persuasion of the salutary nature of the piles, endeavour in some cases to bring them on by giving an aloetic purge. In all hemorrhoidal pains and bleedings, the body should for evident reasons be kept in a state rather inclining to laxity than cos- HERNIA — HYDROCEPHALUS. 93 tiveness; flowers of sulphur in the quantity of ten or fifteen grains have the reputation not only of effecting this in a gentle and proper manner, but of having some further power of soothing the pain and lessening the discharge : however, it is so doubtful whether sulphur have in this disorder any other virtue than that of a laxative, that there might perhaps be safely substituted for it a little lenitive elec- tuary, or a spoonful of castor-oil, or half an ounce of tincture of senna mixed with one ounce of oil of sweet almonds, all which I have seen used with an equally good effect. The pain is sometimes so excessive as to require immediate relief, and this may be procured by means of a cataplasm of bread and milk with a little oil ; or, in a less troublesome way, by keeping the parts anointed with a mixture of a dram of the softened extract of opium and two ounces of any simple ointment. No facts have sa- tisfied me, whether opium act in this case as a topical anodyne, or in its usual manner of affecting the whole nervous system when ap- plied to any part of the stomach or intestines. The pain, if occa- sioned by immoderate distension of the veins, will be lessened, or cease, upon their being emptied either by the point of a lancet, or the application of leeches. I have two or three times been assured by hemorrhoidal patients, that a pint of an infusion of box leaves taken night and morning has greatly contributed to their cure ; but I have never recommended them, because the helps above men- tioned appear sufficient to do every thing that is required, and with as much expedition as the nature of the case will admit. CHAPTER XLV. Hernia. Ruptures require no other remedy, than a proper bandage, or truss. CHAPTER XLVI. Hydrocephalus. The heads of children sometimes grow enormously large, the su- tures give way, and the membranes of the brain are pushed up with the water within, and make a soft tumour rising above the edges of the sutures. This disorder happens to weakly children, and has geen growing upon them above a month. They daily become more and more stupid, with a pulse not above seventy-two. They can hardly be got to take any thing for the last week, even out of a spoon, and seem to have no sense, and hardly utter any sound, and have frequent little convulsions. Upon opening a child who died in this manner, half a pint of water was found in the ventricles. I have no experience of the use 94 HEBERDEN'S COMMENTARIES. of any other means than purging and blistering, and these have not succeeded. The subjects of the hydrocephalus are chiefly children of both sexes, from the first to the eighth year of their lives. Pains of the head, the hands frequently lifted up to the head, sudden ex- clamations, convulsions, stupidity, deliriousness, a slow pulse, and lastly blindness, usually attend the hydrocephalus, and make it sus- pected, even without any unnatural enlargement of the head ; but still these are not constant and infallible signs of a dropsy in the head. No unusual quantity of water was found in the head of a child, who died after suffering all these complaints. An adult was seized with intolerable pains of the head, sometimes had a voracious appetite, and sometimes none, became delirious, convulsed, stupid, and died : the ventricles of the brain were found so distended with water, that as soon as a puncture was made the water flew out to a considerable distance. CHAPTER XLVII. Hydrophobia. I have seen a considerable degree of the hydrophobia in one whose throat had been much inflamed, and was suppurated : but I never saw a case, in which it was the consequence of the bite of a mad animal. CHAPTER XLVIII. Hydrops. Swellings of the ankles or legs towards evening, which vanish or are greatly lessened in the morning, are very common in women while they are breeding, and in hot weather ; and in both men and women when they are recovering from a long illness, and in old age, and after the gout, or any hurt of the legs. These swellings cease of themselves, or continue without any danger, and therefore require no medicine. But where persons after having laboured for some time under complaints of the lungs, or of the bowels, begin to find a swe hng in the legs, it is a sign of some deep mischief in the breast or abdomen, the swelling will most probably increase to a iust dropsy, and the case end fatally. J A dropsy is very rarely an original distemper, but is generallv a symptom of some other, which is too often incurable : and hence arises its extreme danger. Water has often been found in the thorax • but there do not appear to me any infallible signs of a hydrons nee' tons. The nature of this part hinders the swelling from beine- ner" eeived externally, and the respiration is not oppressed bv the watpr in a manner so different from what it is by other causes of the asthma as to afford indubitable signs of its presence. ' A collection of water in the belly shows itself by the swelling, and HYDROPS. 95 by the particular feel upon gently pressing the belly with one hand, and hitting the distended integuments with the other, by which it may generally be distinguished from pregnancy, or wind, or any enlarged solid viscus or gland : yet I have known very experienced persons mistaken in some extraordinary cases. The water in the belly, called an ascites, is frequently contained in a cyst formed from a diseased gland. In women the ovaries very often become the seat of the dropsy, which I have known to continue at least ten years with not much more inconvenience than the bulk and weight must necessarily occasion, this part being perhaps less necessary to life than most of the bowels. I judged it to be the seat of the dropsy by its beginning in the region of one of the ovaries. This dropsy, and some others of the abdomen, will not be accompanied with swelled legs. A very tormenting thirst attends the dropsy most usually, but not universally. In every ascites, where the water is contained in a cyst, or cavity of the abdomen, it is not easy to comprehend how it should ever get into the legs and thighs, after the body had been long in an upright posture ; and perhaps it never does ; the swelling of the legs being occasioned by the great weakness brought on by the distemper, is more properly of the anasarcous kind, arising from the fluid deposited in the cellular membrane, and not derived from the water in the cavity of the abdomen. It is found a matter of great difficulty to carry off this stagnating water, either by purging, or by increasing the urinary secretion, and still harder to do it by sweat; and when this has been done, it is oftener a relief than a cure ; and if no further help can be given by nature, or art, towards removing the original distemper, the patient will remain in as much danger as ever. Great care must be taken in ordering purges for these patients, who are always much weakened by the distemper ; and not to persist in purging them longer than their strength will well bear. When they are capable of bearing such a powerful medicine, I choose to begin with one, two, or three grains of elaterium, which may be commodiously taken in one spoonful of brandy, or any strong distilled water. If the first dose evacuate much of the water, without occasioning too great a ruffle, and so encourage us to proceed, it may be repeated twice a week, till the water be all carried off; on the intermediate days some cordial bitter will be the proper medicine. By this method I have cured four or five dropsical patients, one of whom continued in tolerable health for fourteen years. Gamboge, in the quantity of half a scruple, may be used in the same manner. These rough purges cannot always be borne or continued, and then recourse must be had to the milder, with a view at the same time of increasing the urine. For this pur- pose the prepared squills may be tried, from one to as many grains as the stomach can bear; and, if they be given mixed with the grateful aromatic powders, or essential oils, a large quantity may be given without occasioning sickness. Such a medicine may be directed every night, and one dram of diuretic salt in an ounce of tincture of senna every morning or half an ounce of Rochelle salt or soluble tar- 96 HEBERbEN'S COMMENTARIES. tar; all these neutral salts being, as far as I can judge, from my experience, equally diuretic. The weakness of the patient, or his disposition to purging, may be such, as to allow no room for cathartics, and to admit only of help from diuretics. Many medicines have been delivered down from former physicians as possessed of this virtue ; but it must be owned, that their effects are too uncertain, and often so slight, that whoever relies much upon them, will in most cases be disappointed. One scruple of the active balsams has been given as a diuretic morning and night, and so has the same quantity of salt of tartar dissolved in water or in wine, which is a neater way of employing it, than to give infusions of the ashes of burnt vegetables, all the activity of which may reasonably be supposed to reside, not in the insipid earth, but in their alkaline salt, with which they abound, mixed in the ashes of some plants, with a portion of neutral salts. A dram of spiritus nitri dulcis, or twenty drops of tincture of cantharides, have been used three times a day with the same view ; or a spoonful of the expressed juice of artichoke leaves mixed with two or three spoonfuls of Rhenish wine. When these, and many others which are reputed to belong to the same class, has been tried, as it too frequently happens, in vain, attempts have been made to draw out the water by scarifying the legs, or by applying blisters to them (little blisters will often arise of themselves, without any application, upon dropsical legs), from all which a very considerable discharge is usually procured ; but I have never seen them cure the distemper, though in some instances they have for a small time checked its progress. Both these methods are subject to the inconvenience of making bad sores, notwithstanding the legs are fomented two or three times a day, which also very much promotes the discharge. It is often necessary to let out the water of the ascites by tapping ; the belly being sometimes so violently dis- tended, that the patient seems in danger of bursting, and can hardly breathe. This operation seems to carry off the whole distemper of the dropsy : but there have been very few instances within my ex- perience, where the water has not gathered again, or even where the patient has not died, though the dropsy never returned ; the reason of which is, what was before mentioned, that the dropsy is a symptom only of another distemper, and that most usually a fatal one. In some very rare cases the original bowel disease takes a favour- able turn, and the patient recovers into tolerable health. Among the uncommon occurrences in a dropsy, I have known the tumour sub- side and vanish in a few hours, by a spontaneous flux of urine in an amazing quantity ; the water by some unknown power of an animal body, having been absorbed from its cyst, and deposited upon the kidneys. An event of this sort, and wholly the work of nature, may have given an undeserved reputation to some reputed diuretics which had been so lucky as to have it happen during their use. I have attended a few patients, who from their own judgment and choice have entirely abstained from all liquids ; which they have HYP0CH0NDRIACUS, ET HYSTERICUS AFFECTUS. 97 been able to do for a much longer time than I could have easily believed (at least for forty days, and some have forborne all liquids, as I have heard, for six months), but not with any success, which might encourage others to imitate them. The rubbing of the belly with olive or castor oil night and morning, has been tried with as little success by many, because one or two recovered who had done this. Twice I have observed a dropsy spontaneously disappear. In one case the patient grew apoplectic ; and in the other became de- lirious, and died. A man had an ascites, which by a spontaneous and sudden dis- charge of urine, in a very extraordinary quantity, totally disappeared; but his legs continued to swell for some time, and kept him in fear of a return of his distemper. In this state he was seized with an apoplectic fit, from which he soon recovered. From this time he was troubled with giddiness, and slight threatenings of some apo- plectic mischief; but for many months had no swelling of his legs, nor any signs of a relapse into the dropsy. There is one species of dropsy, called anasarca, which often ap- pears without being complicated with any other disease ; and this is frequently cured, and the patient left in good health. Though this be for the most part void of danger, yet it is not easily removed ; and will for a long time, not only for four or five months, but even for as many years, resist all remedies. Some apparently healthy young persons have had an anasarca ; and I have several times seen it in breeding women otherwise healthy, and upon their miscarrying it has disappeared. It has been accompanied in some with an extra- ordinary flow of tears. I have known it in all ages ; but women are more subject to it than men. Gentle purges, with cordial bitters on the intermediate days, are the proper remedies. The scarifying of the legs has effected a cure ; and so has an opiate given at night, perhaps by the sweat which it occasioned. CHAPTER XLIX. Hypochondriacus et Hystericus Afectus. Few persons, if any, have been blessed with such a constant cheerfulness, as not to have sometimes felt a languor and dispirited- ness, without any manifest cause, which has cast a cloud over all their pursuits, and has afforded only gloomy prospects, wherever they turned their thoughts. This state I call the hypochondriac af- fection in men, and the hysteric in women. While this is in a slight degree, and of short continuance, it passes off unobserved by others, and is not much regarded by the sufferer ; but when the returns of it are frequent, and strong, and of long continuance, it appears to be a misery much harder to'be borne than most other human evils, and makes every blessing tasteless and unenjoyable. It is a sort of waking dream, which, though a person be otherwise in sound health, ^13 98 HEBERDENS COMMENTARIES. makes him feel symptoms of every disease ; and, though innocent, yet fills his mind with the blackest horrors of guilt. Our great ignorance of the connexion and sympathies of body and mind, and also of the animal powers, which are exerted in a manner not to be explained by the common laws of inanimate matter, makes a great difficulty in the history of all distempers, and particularly of this. For hypochondriac and hysteric complaints seem to belong wholly to these unknown parts of the human composition ; the body itself, as far as our senses are able to discern, seeming to have all its integrity and perfection in those who have long and greatly suffered by these disorders. But there is hardly any part of the body which does not sometimes appear to be deeply injured by the influence of great dejection of spirits ; and none more constantly than the stomach and bowels, which hardly ever escape unharassed with pains, an un- easy sense of fulness and weight, indigestions, acidities, heartburn, sickness, and wind in such an extraordinary degree, as to threaten a choking, and to affect the head with vertigo and confusion : the ap- petite however remains good, and is sometimes voracious. The urine is most commonly pale, and in great abundance, but ndi uni- versally. No distemper of the heart occasions greater palpitations, than extreme lowness of spirits, in those where the heart is free from all distempers. Though the lungs be sound, yet the respiration will be performed with all the tightness and oppression of the breast at- tending on an asthma. A sense of fulness in the throat, and of suf- focation, is excited with as little material cause, as far as the senses can judge. Tears flow from the eyes without grief; the nose and ears are filled with ideal odours and sounds : and a mist will seem to obscure the sight. A giddiness, confusion, stupidity, inattention, forgetfulness, and irresolution, all show that the animal functions are no longer under proper command, and that the mind is controlled by some foreign power. The comforts of sleep are in a great measure denied to these patients ; for they have but little, and in it they are harassed with terrifying dreams. • Restlessness, wandering pains, sudden flushings, cold sweats, a constant terror, tremors, catchings, numbnesses, contribute to their misery ; which sometimes so over- powers them, that they either sink under it in a fainting fit, or it is with great efforts and struggling that they can keep from it.* All these symptoms are common to hypochondriac men and hyste- ric women ; but some of them are less, and some more violent in females, and there are others which seem peculiar to them. They * How great a confusion of the senses this disorder is capable of producing, will ap- pear by the following history. A gentleman about thirty years of age, without any obvious cause, fell into a great dejection of spirits, which lasted some time. Aflength, by some perversion of the mind, he seized a razor, and amputated his penis and scrotum. After the wound was healed, he said of himself, it appeared very strange to him that he should have courage to perform such a deed, since he was always at other times of so timid a disposition, that he had great dread even of being bled with a lancet, and could not suffer such a trifling wound without much, agitation. Yet he was free from all fear when he attempted this hazardous amputation ; which he moreover told me was done without his being sensible of the-leafltbaiW. A similar case is related in a book entitled Jlvdical Communicationst vol. jjffj?- {#• MYP0CH0NDRIACUS ET HYSTERICUS AFFECTUS. 99 are seldom so low spirited as the men, but are more apt to have their faculties and passions benumbed, being turned almost into statues, unaffected by occasions of joy or grief. They are far more subject to faintings, and to those universal convulsions, which are called hysteric fits, from which the other sex seems to be saved by their superior strength. These fits will be brought on by the slightest af- fection of the senses or fancy, beginning with some uneasiness of the stomach or bowels. They will last for half an hour, or less, and return frequently every day or even continue for a whole day ; in the meanwhile it is singular, that though the hysteric persons be inca- pable of speaking, and seem senseless, yet they often hear and under- stand everything that their attendants say. After coming a little to themselves, or even without falling into a fit, they will sometimes have a slight delirium upon them, which lasts for several hours. Women differ likewise from hypochondriac men in being much more apt to cry, and to fall into convulsive laughter, or to lose their voice, or utter violent shrieks, and in having hiccups, yawnings, stretchings, and other tendencies to convulsions. The hysteric globe in the throat is scarcely ever heard of among men, but is one of the most familiar symptoms with hysteric women. Man has immemorially been said to consist of s&^a, *»%>,, Not/?, the body, the animal faculties, and the mind. In hysteric women the operations of the animal powers seem to be most disturbed and per- verted ; but in men the mind is the most affected ; involuntary ex- clamations, faintings, and convulsions of all sorts, being most com- mon in women ; and silent despair in men. Hence, perhaps, suicide is more common with men, than among women. Some speculative persons, seeing such evident marks of a design in the author of mankind, that human happiness in every state should be nearly the same, have considered low-spiritedness as the means by which the happiness of the rich and idle is reduced to a level with that of the indigent and laborious part of the species. But it is by no means true, that the poor and industrious are by the lowness of their station sheltered from the tyranny of this malady. Some derive it from their parents; and the seeds of it, brought with them into the world, are sure to make their appearance at the proper time, let the condition of the person be what it may. A dejection of spirits will rob the poor husbandman of the ease and comfort which he should feel when the labour of the day is ended. Neither strength of con- stitution, nor temperance, nor business, nor the gout, afford a certain security. However, idleness will not only foster a disposition to a languor of spirits, but will unquestionably create it; and so will the other extreme, of an oppression from too much business. An intem- perate use of women, and wine, will likewise be its mother and nurse, as well as too great abstinence in eating. Repeated fevers, excessive purgings, terror, and immoderate grief, are no uncommon causes of its appearance in those who before were strangers to it. Hypochondriac complaints resemble the gout, and madness, and consumptions, in their not appearing before the age of puberty ; from 100 HEBERDEN'S COMMENTARIES. which, to the age of sixty, there is no time at which this malady has not made its first visit. There are very few examples of low-spirited persons who find themselves worse at night than in a morning ; the generality of them, like most of those who are afflicted with any of the complaints styled nervous, are hurt by their sleep, little as it is; and the longer they happen to sleep, the worse they are ; they awake out of it in confusion, and do not come immediately to themselves; and when they do, they can think only of melancholy subjects, and feel the worst horrors of their disorder. This state continues till din- ner, with very little abatement: after dinner they feel themselves a little revived ; and at night the tide of their spirits returns ; which being desirousto enjoy, and dreading their certain ebb when they lie down, they go late and with reluctance to bed. Three persons employed in examining and smelling tea, have sus- pected that it occasioned tremors and other hypochondriac ills. The seasons of the year have not appeared to have any constant influence in relieving or exasperating a disposition to melancholy. Though extreme dejection of spirits seems so nearly related to epilep- sies, madness, and palsies, yet it is not common to see it end in any of these disorders. It is the condition of this malady to make the patient hopeless of a cure : but neither reason nor experience justifies his despair. For every part of the body, as far as our senses can judge, is whole and uninjured by his sufferings, great as they are ; and the mind and ani- mal powers are indeed oppressed, and cannot exert themselves, but their abilities are all entire; Hypochondriac and hysteric persons will look well, and grow fat with their complaints, and have now and then respites from them, in which they have all the sensations of most perfect health. It is well known, that some extraordinary works of genius have been the offspring of the intervals of melancholy. This malady will sometimes cease spontaneously ; and I have known it leave a person, without any returns, for near twenty years. Now, what more encouraging circumstances can there be in an illness, than to know that the life is in no danger from it, that Tt is not incurable, and that, when it is removed, the patient will become as perfectly well as if he had never experienced it ? s In the cure of all chronical distempers, it is a matter of great im- portance to put the general health, by a proper regimen, into the best state possible ; by which the self-correcting principle of an animal body will be enabled to exert itself with the greatest vigour • and this, in some diseases, is the whole of what can be done ' This therefore must be carefully attended to in a languid state of spirits by avoiding all the general causes of ill health, together with all the par- ticular ones before mentioned, which may be conjectured to have brought on, or to have aggravated this malady. Evacuations are very ill borne in this disorder ; but as it is usually accompanied with costiveness, we need not scruple to give occasion- ally three or four grains of Rufus's pill, or a small portion of any other gentle aperient so as just to procure one motion every day • for HYP0CH0NDRIACUS ET HYSTERICUS AFFECTUS. 101 this will mitigate, or prevent many of the bowel complaints. A gen- tle emetic may also be sometimes wanted, when the stomach is un- commonly loaded and sick. All further evacuations, and particularly bleeding, scarcely ever fail to heighten every symptom. It is so little in the power of any medicines to give the gout, and it is so uncertain whether the gout would take away the hypochondriac complaints (for in some persons I have known it constantly bring them on), that I think it nugatory to attempt a cure by giving any medicines which are supposed to create or to excite a fit. Bath waters, according to my experience, are at least useless, unless in some extraordinary dis- orders of the stomach; and the going thither, or a sea voyage, or foreign countries, can only be advisable when they will remove the patient from a scene of grief, or cares, or too much business. Sea- bathing, and chalybeate waters, may be serviceable upon the same ac- count ; and may besides, in some cases, improve the general health. The gum-resins, and wild valerian root, and steel, have the credit of possessing a specific virtue in all maladies attributed to the nerves ; my experience of them will not add much to their reputation. The nerves of the stomach and bowels have so great a dominion and con- trol over the whole nervous system, and these parts are so generally disordered in hypochondriac and hysteric patients, that, in my judg- ment, the best medicines will be such as correct their acidities, and are known by experience to be efficacious in recovering them to their proper strength and functions. This purpose is best brought about by the aromatic and bitter medicines, with which a small proportion of aperients may be joined when they are wanted. These may be given in pills, in drops, in tinctures, or infusions; and by this variety of forms, and by the small compass in which they may lie, they may easily be continued, as long as may be necessary, without becoming nauseous. Many in a lowness of spirits are not indisposed to raise them by wine and spirituous liquors ; and they are encouraged and pressed to do it by their well-meaning but ill-judging friends. No words can be too strong to paint the danger of such a practice in its proper colours. The momentary relief is much too dearly bought by the far o-reater languor which succeeds ; and the necessity of increasing the quantity of these liquors in order to obtain the same effect, irrecovera- bly ruins the health, and in the most miserable manner. If the anx- iety of dejection becomes intolerable, and must have some present relief, it is better to seek it in opium than in wine. A few drops of the tincture of opium, with or without the tincture of asafoetida, or antimonial wine, would be a much safer cordial for the drooping spirits than spirituous liquors ; and might be increased without equal danger of hurting the health, and without bringing on the same diffi- culty of ever leaving it off again. My experience has often taught me, how safely and consistently with business, a course of taking opium may be continued for a considerable part of a man's life ; and how practicable it is to be weaned from the habit of it: while every body's experience must have shown them the danger of persisting 102 HEBERDEN'S COMMENTARIES. in a course of drinking immoderately, and the almost impossibility of ever reclaiming a sot. I would by no means be understood, by any thing which I have said, to represent the sufferings of hypochondriac and hysteric pa- tients as imaginary ; for I doubt not their arising from as real a cause as any other distemper. However, their force will be very different, according to the patient's choosing to indulge and give way to them, or to struggle against and resist them, which is much more in his power than he is aware of, or can easily be brought to believe : and it is surely a cause worthy of any one's utmost endeavours and exer- tions. For his striving to shake off this distemper is not contending about a frivolous concern, but whether he shall be happy or misera- ble ; since it is of the essence of this malady to view every thing in the worst light; and human happiness, in many instances, depends ' not so much upon a man's situation and circumstances, as upon the point of view in which he contemplates them. CHAPTER L. Icterus, aliique Hepatis Ajfectus. The obstruction of the gall-ducts from gall-stones is the most common, but the least dangerous, of all liver complaints ; for it ad- mits more relief from art, and is often surmounted by the unassisted efforts of nature. The bile, from causes not hitherto clearly understood, frequently thickens into grumous lumps, which gradually harden into an al- most stony substance. It seems probable that these gall-stones, as they are usually called, are generally formed in the gall-bladder. This, I think, or the ductus choledochus communis, is the place in which they are most frequently found, and often, when the liver is so perfectly sound as probably to have had no share in producing them. At least, it must be owned that the gall-stones acquire their chief bulk in the gall-bladder, though it should be judged that the nucleus comes hither from the liver. The contents of the gall-bladder are naturally poured through the ductus cysticus and choledochus communis into the duodenum. Together with the bilis cystica the gall-stones readily pass, if they are* very small; and if they are large, they sometimes lie quiet in the gall-bladder, without being at all perceived, and sometimes make frequent efforts to get into and pass the gall-ducts ; in the beginning of which, or in any part of them, if they happen to be stopped, they of course obstruct all, or most of the gall, that should flow into the intestines, which therefore is forced back into the liver and thence into the blood, tinging the serum, and consequently the skin and eyes, of a yellow hue, and deepening the natural colour of the urine, so as to make it of a very dark yellow, or brown.* * The urine of one person in a jaundice, after standing a few hours, changed from a deep yellow to a green colour. The same change may be observed in yellow bile a little while after it has been vomited. ICTERUS, ALIIQUE HEPATIS AFFECTUS. 103 The usual symptoms of the gall-ducts thus obstructed are, loss of appetite, sickness, vomiting, languor, inactivity, sleeplessness, and if the obstruction be continued for a few days, a very great wasting of the flesh. These complaints are remarkable in the obstructed gall- ducts, but they belong to many other diseases. The most distin- guishing signs of this malady are, a yellowness of the eyes, skin, and urine, and a want of this colour in the stools. Nor is this dis- order much lesscertainly denoted in some patients, before the yellowness appears, by an exquisite pain about the pit of the stomach, the pulse being at the same time as slow as a natural one : and by an atten- tion to these two circumstances, it is not difficult to foretell the out- ward yellowness, in many cases, some days before it appears. The slowness of the pulse will almost always distinguish this pain from one which belongs to an inflammation of the bowels; and wherever, together with this pain, the artery beats in the usual manner, the physician will have the great satisfaction of being able to assure the patient, that his pains can be relieved, and that they are not of a dangerous nature. But this pain, which sometimes is hardly supportable in the jaun- dice by persons of the greatest patience and courage, rises in others only to a slight uneasiness about the region of the liver, or is not felt at all. This perhaps may be owing to the different parts of the gall-ducts in which the stone happens to lodge. There is great rea- son to believe that the liver itself has little or no sense of feeling; and it is probable that not more belongs to the gall-ducts. But every day's experience acquaints us how exquisitely this sense be- longs to the intestines. It may therefore be, that little or no pain is felt while the stone is forcing its way through the gall-ducts, till it come to the end; but in stretching that part which is inserted into the duodenum, the intestine is, by a large or angular stone, distended or irritated, to a degree which may account for all the torture that ever attends the jaundice. This pain seldom lasts, without inter- mission, above two or three days; but I remember its continuing in one person near a month, without any intervals of ease, except what were procured by opium. Wherever this pain is felt at all, it not only comes before the yellowness, but is sometimes more, sometimes less, sometimes entirely disappears, and then rages afresh, through- out the whole fit of the jaundice. There sometimes appears reason to suspect a stone in the ducts of the liver, from the presence of all the other symptoms, though there be no yellowness in the eyes or skin ; which suspicion has been verified by the voiding of a gall-stone, with the relief of all these symptoms ; or after frequent returns of them without any discolour- ing of the eyes and skin, by having one of these fits end at last in a jaundice. WThether it be, that in these cases the stone is of such a form as not perfectly to fill up the aperture, or that the violent efforts of vomiting, without dislodging the stone, force some bile between it and the sides of the duct. And as a gall-stone may sometimes be suspected without any 104 HEBERDEN'S COMMENTARIES. marks of it in the eyes or skin, so this yellowness is said to be found without any gall-stone or preternatural consistence of the bile. It has been supposed that an infraction of the duodenum may be great enough to hinder the efflux of the bile: but this may be questioned, if we reflect that the duodenum has seldom any solid contents in it, and that if it should be so plugged up by them, or compressed by the distention of the other intestines, as to hinder the passing of the bile, it would for the same reason be incapable of admitting any thing into it from the stomach ; which is a supposition hardly counte- nanced by experience. Sydenham mentions the jaundice as no uncommon symptom in hysteric cases, where there is no disorder of the gall or gall-ducts. No reasonable deference to this accurate observer can make any one much doubt of his having been mistaken, because nothing like this has occurred to very many other practitioners, as they have assured me, though hysteric complaints be so very frequent: and it requires but a very moderate understanding to see, after it has been pointed out, what could not have been discovered but by one of superior sagacity. A perfect jaundice is said by physicians of unquestionable au- thority to be an attendant upon some fevers, and particularly upon the yellow fever of the West Indies. It is also said to be produced by the bite of a viper. And in these cases it is judged to be owing to a convulsive stricture of the duodenum. Of all which I am no judge, as I have never seen these disorders. There is in many ex- hausted and cachectic persons a skin almost of the colour of a lemon, in which the bile is not concerned ; but then they have not yellow eyes, and dark urine, and ash-coloured stools, which I have never yet happened to see, without the strongest reason to suspect the gall- ducts obstructed by bilious concretions, or scirrhi. It has long been a prevailing opinion, that every object appears yellow to the eyes of a person in the jaundice: " Lurida prseterea fiunt, quaecunque tuentur Arquati:"----------- is the assertion of Lucretius ;* and the same has been allowed by some physicians. Now, though the tunica conjunctiva be tinged with this ail, yet, as the milk in the breast preserves its whiteness, it is not probable that the much finer humours of the eye, through which the light is transmitted to the optic nerve, should ever be in- fected ; nor if they could, would it thence follow, that all objects would appear yellow : accordingly all the jaundiced patients, whom I ever asked, have unanimously denied the truth of this pretended fact; excepting two women, whose testimony was very suspicious. The duration of the jaundice is extremely various, and uncertain. In some patients it will disappear in two or three days ; in others I have seen it continue near a twelvemonth, before the gall-stone could pass into the intestine, or fall back into the gall-bladder: nor will this long obstruction of the natural course of the bile have any * Lib. iv., ver. 333. ICTERUS, aliique iiepatis affectus. 105 lasting ill effects, or hinder the patient from being soon reinstated in perfect health, after the removal of the obstruction. I have known the jaundice return frequently for more than twenty years in some persons, who have had goodvhealth in the intervals of the fits. There is no limit to the possible size of gall-stones, except the capacity of the gall-bladder ; and they are found of all intermediate magnitudes between this and the minutest dust. When the gall- stone becomes too large to enter the duct, it is probable that its lying in the cystis may be attended with some, though I know not what, inconvenience; but it is often-, we are sure, a very slight one; for many have been opened after their death, in whom a very large stone, or many small ones have been found without their ever having had in their life-time any complaint, which could certainly be im- puted to this cause. I attended a woman, who for five years laboured under all the usual symptoms of the jaundice in the highest degree. In the sixth year she voided a gall-stone like a small olive in shape and size ; after which she enjoyed good health for many years without any re- turn of jaundice, or the appearance of a disorder which could be imputed to her once having had it. The passing of such large stones shows what great efforts nature is capable of making towards freeing itself from such an incumbrance. The natural size of the gall-duct hardly exceeds that of a goose-quill; and a force may be exerted which will distend this narrow passage so as to let a stone pass, the smallest circumference of which equals two inches: I speak only of what I myself have seen: others give us accounts of the passing of much larger. In the gall-duct of one woman, whom I had attended, there was found after death a gall-stone as big as a small hen's egg. I have had an opportunity of examining the gall-ducts of some, whom I had frequently seen in fits of the jaundice; and I found them much distended beyond their natural diameter throughout their whole length, but very unequally. The same appearances are very common in the ureters of those, who have had many stones pass from the kidneys to the bladder. The liver of these persons, though they had for many years suffered frequent fits of the jaundice, was perfectly sound. It is frequently recommended to the attendants upon icteric pa- tients to examine their stools, in order to find the gall-stones, and there can be no reason to hinder them from doing it; but the other signs of this disorder are so certain, that the finding of a gall-stone will add very little to the evidence for the nature of the disorder, and will be of no use to the cure. For whether a gall-stone be found or not, the method of cure must be continued as long as the symptoms remain, by which alone the physician must be directed. Let there be ever so many gall-stones found, if the patient be not relieved, it must be supposed that more remain : and consequently the same medicines must be continued: and, on the other hand, though there be none found, if all the complaints cease, the proba- 14 ion HEBERDEN'S COMMENTARIES. bility is that the stone is fallen back into the cystis, and therefore little or nothing more is to be done. Some gall-stones, which I have weighed, have been heavier than water, and others have been to water as nine to ten. Ihey melted also by heat, and were inflammable. I have examined only a few in this manner ; and possibly there may be a great difference between these and others, in the texture and materials of which they are com- posed : most of what I have seen were of a dark brown colour ; but some have been almost white externally, though brown within. A very troublesome itching, but without any eruption, is often ob- served in the jaundice : this is supposed to be owing to the irritation of the skin from the acrimony of the bile mixed with the blood : but it is not easy to say, why this, or any other cause, should make this complaint so exceedingly distressful to some, whilst it is not at all felt by others. In a simple jaundice, without any apparent disorder of the liver, or other viscera, a hiccup will now and then join itself to the other symptoms, but without denoting any present or future mischief. It might naturally be expected, that the want of irritation from the bile should make icteric persons costive ; but in fact they are often disposed to have a purging. Certainly neither of these states is peculiar to their distemper ; and the spontaneous diarrhoea, or the readiness with which a costiveness is removed, may help to distin- guish it from the ileus. In other disorders of the bowels, it is a very alarming symptom, to have the patient subject to fits of shivering : but very strong ones now and then happens in the jaundice, and last an hour, and return every day for two or three times, without being followed by any other complaint. It is difficult to guess satisfactorily at the cause of this : but whatever it be, I have suspected that this symp- tom happens at the time of the stone's passing into the intestines. However, neither suppuration, nor gangrene, nor any other mischief, needs be apprehended from this shivering. It is not constant in this malady, but it is far from being un- common, to have all solid food taste bitter ; and sometimes, though more rarely, the same is true of liquids. I knew one, to whom all liquids, and solids, tasted bitter, except oysters. The milk of icteric women, who suckle children, is not tainted with the bile, either in its colour or taste. I remember to have seen a woman, who with a very deep jaundice had been for six weeks suck- ling a child, who sucked with eagerness, and was healthy and robust. One man assured me his tears were tinged in a jaundice. Infants, and children of all ages, are subject to the jaundice : but mey have it in a slight manner, and soon recover from it; and it does not, as far as I have observed, do them any hurt. Men and women seem equally liable to this malady : in a continued succes- sion of a hundred patients, I counted fifty-two males, and forty-eio-ht females. They who have once had this distemper, are very liable to returns ICTERUS, ALIIQUE hepatis affectus. l(;7 of it; not only because other gall-stones are likely to be generated by the same causes which formed the first, but likewise because a fit of the jaundice is frequently terminated, not by the passing of the stone into the duodenum, but by its falling back into the cystis ; at its passing out of which it occasions a fresh fit; and many may be thus caused by the same stone. A jaundice, caused merely by an obstruction of the gall-ducts by a stone, is usually void of all danger ; so that many people are not hindered by it from doing all common business of life, where no great exertion of strength is required. Very different is the danger in diseases, which properly belong to the liver itself. This viscus seems in some ii stances to have been seized with a sudden and violent inflammation, joined with a fever, and with signs of immediate danger ; which are neither followed by a speedy death, or by a lingering one, after an unkindly suppura- tion, which though more slowly, yet is scarce less certainly fatal. Such an inflammation perhaps more usually begins in some of the parts to which the liver is contiguous, and is communicated to it from them. But what I have conjectured to be this distemper of the liver has rarely occurred to me, in comparison of that which begins here, as in other glandular parts, with a small scirrhus, which gradually spreads itself over its whole substance, and, I imagine, just in the same manner as it happens in the breasts of women. These scirrhi by fits inflame, whence a fever is raised, and the health in many respects much discomposed. This fever retreats on the abatement of the inflammation, and the patient is encouraged to hope for a recovery; but his hopes are usually vain ; the inter- vals between these inflammations becoming shorter, the appetite, flesh, and strength decreasing with a little cough and hiccup, which sometimes without, and often witb a dropsy, bring on death ; towards which the progress in different patients is so unequal, as either to take up several years, or to be finished in a few months. The liver, having but a very dull, if any, sense of feeling, if the inflammation be confined to the interior parts, it will hardly be at- tended with any pain ; which, as I suspect, is never perceived, but when an ulcer, or inflammation of the surface of the liver, catches the diaphragm, intestines, or parietes of the abdomen. In this state of the liver the patient choose to lie on their right side. A pain of the right shoulder is common in liver cases ; but on what circumstances it depends, no observations have yet ascertained to me ; nor whether it belongs to a mere obstruction of the gall-ducts, or only to scirrhous inflammations of this part; which last I rather stupect. In the advanced state of these scirrhi, the blood will gush out in great quantities from the nose, the gums, the stomach, the navel, and with the stools; which is probably to be attributed to the ob- struction which it meets with in the scirrhous liver. The worst of these cases, of which I have satisfied myself by see- ing the bodies opened, will sometimes, throughout their whole course, 108 HEBERDEN'S COMMENTARIES. show no signs of jaundice ; that is, though the complexion may be of a leaden colour; yet the skin and eyes and urine will be free from the jaundice-tincture, and the stools will not be ash-coloured, the reason of which may be this ; that the diseased parts of the liver are so situated, as not to intercept the course of the bile in its passage from the sounder parts of the duct. An indurated liver is often very evidently distinguishable by apply- ing the hand to the region of it: and this affords another certain sign of its diseased state. These are the only peculiar signs, that this viscus is the seat of any malady ; for the quick pulse, hiccup, sickness, and averseness from food, equally belong to the distemper of the liver, and of many other viscera. 1 doubt indeed whether it be of any great moment to be able to decide with preciseness, whe- ther the ail be here, or in the pancreas, or spleen : for I know of no remedy peculiarly or specifically appropriated to this state of the liver; and there is not much more to be done in it, than what the common cure of the hectic fever requires, whether the fever arise from this, or from any other cause. It is probable, if a small part only of the liver be scirrhous, that it may, by a cool regimen, and by assisting the general health, be kept for many years from spreading. Where frequent inflammations, with a considerable degree of fever, cannot be prevented, there the flesh and strength more rapidity de- crease ; and if the inflammation be great enough to occasion a sup- puration, the only chance of a recovery is from the breaking of the abscess in such a manner, as that the matter may be carried off by the hepatic duct, or when the inflammation of the liver has made it adhere to the parietes of the abdomen, in which a tumor forms, and is opened, or burst, externally. I have known one or two re- cover in such circumstances, but more who have sunk. In some, a great abscess of the liver has appeared to have made its way pre- ternaturally into the stomach, or bowels; and immediately, upon the bursting of it into these parts, the patients void, by vomiting and purging, a most offensive matter, filling a whole house with its noisome smell, and die in a few hours. A woman fifty years of age was for ten days severely afflicted with pain of the stomach, hiccup, purging, and faintings, and with diffi- culty struggled through it. A month after there arose a swelling near the navel, which was opened, and discharged a great quantity of yellow fluid for the space of four years ; at length the pain increased, together with sickness, and shivering, and after a few days there was discharged a gall-stone three inches long, and as much in circum- ference, weighing 245 grains. During the two following weeks a thin liquor was poured out in great abundance : soon after the sore healed up, and the woman recovered. It is evident the gall-bladder must in this case have inflamed and suppurated. A sudden inflammation of the parts contiguous to the liver, by which it would soon be affected, or possibly of the liver itself, may be occasioned by any of the causes to which pleurisies and similar icterus, aliique iiepatis affectus. 109 disorders are owing. The more chronical diseases of the liver, which begin with small scirrhi, arise sometimes from the same ill habit of body which occasions scirrhi in other glandular parts, or from a blow ; but the most common cause is an intemperate use of spirituous liquors, which specifically hurt the liver, far more than they do the stomach, to which they are immediately applied, or than they do any other of the bowels. Men are more commonly affected with scirrhous livers than women, because they are more given to intemperate drinking, which is the principal cause of this disorder. Bath waters are in no cases more useful, than in remedying many of the injuries done to the constitution by drunkenness : but where the liver is become scirrhous, and a hectic fever shows these scirrhi to be in an inflamed state, there the Bath waters will aggravate all the symptoms, and contribute no otherwise to end the disease than by hastening the patient's death. In the cure of those whose gall-ducts are obstructed by biliary con- cretions, the first thing to be attended to, is the pain; which is often so excessive, that nothing else ought to be attempted, before this is relieved. Bleeding is here of no use, and should therefore be for- borne as a needless waste of strength. This pain can only be as- suaged by giving and repeating opium, or its preparations, as often as the continuance of the pain requires them. And because this pain is very apt to return, the patient should always be advised to keep by him, as long as the distemper lasts, pills of pure opium, each weighing one grain, or what is equivalent to them, that no time may be lost in quieting a sensation which it is so difficult to endure. One of these pills may be taken as soon as the pain comes on ; and it may be repeated once or twice in the space of two hours, if the pain re- quires it. I have found it both safe and necessary to give much more. Vomiting is commonly the next symptom which demands the phy- sician's assistance. This seems to be an effort of nature to dislodge the stones ; but it may be a question, whether it be such an effort as ought to be encouraged, or checked; for though on the one hand this violent concussion may force the stone back into the cystis, or forward into the duodenum, and so effect either a temporary relief or a perfect cure, yet it may be feared, if the stone be so fixed in the duct, as not to be easily moved, that the action of vomiting will lacerate the membranous duct, and be the cause of future mischief, as well as of present pain. Now, whether this fear be just, or ground- less, can only be determined by experience ; and by what I have ob- served of icteric cases, it has appeared to me, that a vomit excited, while the pain was intense, has rather quieted than aggravated it, and has never brought it on. But if we be secure of its doing no harm, there is so good a chance of its being beneficial, that, whether the patient have a vomiting or not, it is a judicious practice to order an emetic, either at first, or as soon as the 'intenseness of the pain has been alleviated, and occasionally to repeat it. To excite a vomiting 110 HEBERDEN'S commentaries. in this malady is much more easy than to stop it; and therefore it is always proper, and sometimes necessary, to order an opiate to be taken after a moderate number of strains have been procured, or if the sickness continue longer than usual. Similar good effects may with reason be expected from purging medicines, by their increasing the natural motion of the intestines, and soliciting a greater flow of bile, as well as of all the other humours which are poured into them. Mercurial purges have been preferred by some practitioners : but there appears nothing in the known powers of mercury peculiarly useful in dislodging a biliary concretion ; and the preference should be given to those purges which act with the most ease, and may be continued with the greatest safety. Such are the sea-water, the water of many purging springs, as also many of the neutral salts, dissolved either in water, or, if it can be borne, in a weak infusion of some bitter vegetable substance. These, as we know by abundant experience, may be taken for several months, either every day, or every other day, without palling the appetite, or ex- hausting the strength or spirits. But in some cases there may be reason for using other purgatives; and I have known a few grains of rhubarb, or one or two drams of tincture of senna, or of rhubarb, taken with advantage in a small draught of some moderately bitter infusion. The jaundice of infants and young children soon yields to a few purging medicines. If it happen that the jaundice is of itself attended with a purging, there may be nothing further necessary, than by gentle means to pre- vent its being excessive, and at the same time to strengthen the stomach by proper bitters. The itching is many times so extremely troublesome, as to require opium ; without the help of which it would be impossible to procure any ease or sleep. Beside these medicines, which have appeared to me the most beneficial of any which I have seen used, there is a class of bodies which have been trusted to, from a belief that they have a power of dissolving gall-stones. Of this kind are the alkaline salts, lime-water, soap-leys, and various soaps : all which I have tried by steeping gall- stones in soap-leys, and lime-water, and in the solutions of soap, and of the salts ; and it is no wonder, that the others did nothing towards dissolving the stones, when the most powerful of them all, the strongest soap-leys, could only fetch out a slight green tincture from a gall- stone, but neither seemed to lessen its bulk, nor to alter its shape, in several months ; and there is very little likelihood of their being able to do more in the body than out of it. Gall-stones were likewise infused in every one of the acid spirits, without being dissolved in any. But if we had ever such powerful solvents of gall-stones, it might be doubted whether they could do any service in the obstructions which these occasion ; for whilst they remain in the ducts or cyst the solvents cannot reach them ; and when they are come'out into the intestines, they want no medicines, but will of course be voided by stool. ICTERUS, ALIIQUE HEPATIS AFFECTUS. Ill It would be very desirable to find out a remedy, which would medicate the bile, so as to make it unapt to coagulate, or enable it to resolve the concretions already formed ; and such there may be found hereafter; but though this has been pretended of several, I have no reason to think it true of any; and as we do not yet know any which may be safely taken, which can dissolve gall-stones, it is not likely that we know anything which will make the bile dissolve them. I attended a person, who for a stone in the bladder of urine had been in a course of swallowing an ounce of soap every day for seven years. His distemper and advanced age having made him retire from all the business of life, and he being naturally constant in what he undertook, I imagine there could be very few days, and I do not know that there were any, on which this medicine was omitted. His body was opened after his death, and, notwithstanding such an ex- traordinary quantity of soap had been taken, a great number of stones were found in the gall-bladder, which showed no sign of having been acted upon by any solvent. The only use of soap and alkaline salts in a jaundice, as far as we can reason upon their probable virtues, is, to make amends for the deficiency of the bile, which they resemble, in digesting the food, and cleansing the bowels. But too much stress must not be laid upon this reasoning ; for I have known large quantities of an acid, such as lemon-juice, taken by some icteric patients, with so much apparent benefit, as to have gained the credit of the cure. A very judicious physician assured me, that he had seen extremely good effects in an inveterate jaundice from a scruple of volatile alka- line salt given three or four times a day ; and he seemed to be con- vinced, that, besides the virtues just mentioned, it had some peculiar or specific ones in the cure of this disease. Specifics for it are to be met with in great abundance among medical writers, many of which manifestly owe their reputation to inconclusive reasoning, or to fanciful criteria of the virtues of medi- cines ; others are unsupported by well-attested experience ; and I have no reason, from what I have observed, to think the testimonies in favour of any of them deserve to be examined, or mentioned. The waters of Bath have some credit of being serviceable m a jaundice. But it must be observed, that icteric patients generally recover wherever they are, and it may be doubted whether they re- cover the sooner for the use of these waters. However, there can be no medical reason for dissuading any one, in a simple jaundice, from going to Bath ; because the waters are perfectly safe, and the proper medicines may be taken there, as well as any where else ; while the vacancy from care in such public places, together with the change of air, and water, and objects, may be of some use to the general health, and thereby facilitate the cure of this, as they often do of many other chronical disorders. Before I conclude, it may be of some use to observe, that biliary concretions are probably one cause, amidst various others, of that 112 HEBERDEN'S commentaries. commonest of all complaints, an uneasiness, or pain, as it is called, of the stomach. This I have been induced to believe, from finding that in many persons a pain of the stomach, which had frequently afflicted them for months, or years, has at last been joined by a jaun- dice. When therefore a pain of this kind frequently returns, without any other manifest cause, especially if there be at the same time a sensation of fulness, a thickening of the bile may generally be sus- pected ; and gentle vomits, and a course of purging waters, or any other mild purgatives, will prove the most effectual cure. CHAPTER LI. Jleus. The ileus, or inflammation of the bowels, has for its subject chiefly adults, and especially those who have ruptures, or who perhaps from some less apparent, but equally unnatural situation or conformation of the bowels, have often been afflicted with colicky pains. Yet childhood is not exempt from this very dangerous disorder : some have died of it in their sixth or seventh year with all the usual symp- toms ; and it is not unlikely, that this may make one of the many bowel disorders which are so fatal to children for the first three or four years of their lives. It begins with a pain usually referred to the stomach or the bowels : this sometimes comes on suddenly, and with violence ; or from small beginnings gradually increases ; and in rare cases has even seemed to abate for a few days, and then has returned never to yield again to any remedies. The navel has been complained of, and so has the back, as the chief seat of the pain, even in those who have had in- guinal ruptures; which have undoubtedly been often the original cause, but, as I suspect, not always the seat of the inflammation ; and in some cases the colic may have nothing to do with a hernia, which the patient chances to have, but is wholly owing to some of those causes, which produce it in persons who never were ruptured. Eructation of wind, which usually accompanies this illness, and like- wise the action of coughing, aggravate the pain to a degree hardly tolerable. It has happened in one or two instances, that the ileus has from the very beginning occasioned restlessness and uneasiness rather than pain, even in those, after whose death a portion of the intestine has been found sphacelated. The pain in those who recover, is changed into soreness, with a manifest relief of all the other symptoms ; and into restlessness in those who die, all the other symptoms at the same time becoming worse. The duration of the pain, before it makes a favourable, or fatal change, is very various, accordingly perhaps as there may be a small portion of one, or a large part of several of the intestines inflamed ; and according to the greater or less influence of those causes which retard or hasten the progress of inflammations towards a cure, or a gangrene : so that the distemper ILEUS. 113 has destroyed the patient on all days from the second to the four- teenth. It is obvious, that a violent injury by a blow, or fall, or by some corrosive poison, may excite such an inflammation of the bowels, as will be fatal on the first day, or in a few hours. The state of the pulse is of great importance in ascertaining the nature of those symptoms, which the colic has in common with icteric and spasmodic complaints, where the vomiting and pains are some- times as great, but without any danger; for in the ileus it almost always has a feverish quickness, but in the others it beats in the natural manner: and yet for some cause, about which I can form no conjecture, it happens, though very rarely, in this and in other in- flammatory and malignant cases, as has been elsewhere mentioned, that the pulse continues in a natural state, giving not the least notice of danger, or of approaching death.' I have observed this thrice in the ileus. A hiccup, and an unquenchable thirst, often come on early in the distemper, and tease the patient through its whole course. There is such a disposition in the stomach to reject every thing, that it is often difficult, even in the beginning of this malady, to con- trive any food or medicine which can be kept. Afterwards, besides what has been taken down, there is vomited up a brownish liquor, of which I have heard many patients and their nurses say, that it affected their senses like excrement; and therefore I suppose it to be so, though it never struck me as having a stercoreous smell. The old medical writers likewise call it liquid excrement. This has made its appearance on the first or second day, but has not usually been observed sooner than the third or fourth ; it has been delayed till the eighth. Above two quarts have been vomited up daily for six or seven days, during which the patient hardly took any thing. It is probably supplied in the same manner as the evacuations in a violent diarrhoea. From this symptom it has been concluded, that, at least in some cases, the ileus arises not from a stoppage or stricture in any part of the bowels, but from their inverted motion ; which opinion is confirmed by what I have heard the patients and their attendants assert, that clysters had been vomited up ; which has happened even where the mischief has arisen from an inguinal rupture, in which it has been supposed that the intestine was strangled in the ring so that nothing could pass. In the instant of dying, an inundation of this liquid has suddenly burst forth upwards and downwards. This sort of vomiting, together with a great inflation and tension of the belly, are symptoms of the utmost danger; yet some are said to have re- covered after these appearances ; but instances of this are, I believe, extremely rare. When the pain goes off without the patient's being relieved in other respects, a restlessness and anxiety either come on, or are in- creased to a most distressing degree. Notwithstanding the inquie- tude, and want of sleep, and the great violence which must be done to the powers of life by this very formidable disease, yet it hardly ever happens that the patient is delirious. 15 114 HEBERDEN'S COMMENTARIES. The peculiar and distinguishing symptoms, which characterises the inflammatory colic in the very beginning, is a costiveness ; which it is always extremely difficult, and too often impossible to con- quer. As soon as a discharge downwards can be procured in a co- pious manner, the patient perceives a quick abatement ot all his misery, and is soon restored to health. But it is not from one or two small evacuations, that we can entertain much hope of the dis- temper's beginning to give way. This has happened on the first or second day from the excrement which was lodged in or near the rectum, far below the seat of the mischief. And later in the dis- temper, a very small portion of that liquid matter, with which the bowels are deluged, has seemed to have been forced downwards, while the disease was every hour growing worse. Such ineffica- cious evacuations have been observed more than once or twice in the course of this illness, without saving the patient's life : and two or three of them have come away not many hours before a coldness of the extremities came on, and was soon followed by death. Upon dissection, there have been found in some bodies, strictures, subsisting after death so strongly, that when the gut was cut in two, the cavity seemed entirely obliterated. In others there have been various portions of the intestines discoloured and sphacelated, but without any stricture or obstruction throughout their whole length. In an inguinal rupture, the intestine surrounded by the ring, was so far from being strangled, that two fingers could pass between them; and the gut in that part had been less inflamed than what had fallen into the scrotum, which was black and mortified. Death perhaps might have made some alteration in these appearances. A person has died with all the usual symptoms of the ileus, where the only part affected was half the circumference of the outward membrane of the colon, which for the length of five inches was black. A very small portion of the gut, and empty of all contents, so that it was imperceptible externally, had fallen into the groin, and was morti- fied, in one, who died on the fourteenth day of the disease. This account of the ileus shows that all heating things must be avoided, which have been too often given ; and that its cure must depend upon the success of those means which abate inflamma- tions, and procure stools. The first of these purposes is best an- swered by bleeding, as often as it is judged that the symptoms re- quire, and the strength of the patient will bear. Warm bathing will greatly assist the good effects of the bleeding, and cannot be re- peated too often : it very rarely fails of giving a temporary relief, by procuring a perfect respite from the pains, as long as the patient continues in the bath. Fomentations, and bladders half full of warm water applied to the belly, are weaker remedies of the same kind with the bath. The application of a blister to the same part has been attended with apparent benefit, and acts perhaps both by moderating the inflammation, as when put upon the side in pleu- risies, and also by correcting those spasms which obstruct, or invert, the natural motion of the intestines. ILEUS. 115 All these helps are greatly serviceable in disposing the bowels to yield to the power of cathartic medicines ; by the failure or suc- cess of which the life or death of the patient must at last be de- termined. It is a misfortune that the taste of purging drugs is gene- rally disagreeable and nauseous ; especially as a loathing of every thing, and a vomiting, are symptoms which distress these patients in the very beginning. Hence arises a very great difficulty of con- triving any purgative, which can be taken and kept. However, they who can swallow pills, have very readily taken five grains of cathartic extract made into a pill, and repeated it every half hour until it had the proper effect. One or two spoonfuls of a strong so- lution of cathartic salt in weak broth, or in peppermint water, has often been retained, when nothing else would stay upon the sto- mach. The infusion of senna, given in the same manner, has some- times been borne ; and so has even the castor-oil. In a very few instances I have known this oil rubbed for a considerable time over the belly, where the patient has thought that this mode of using it contributed not a little to the bringing on a proper and plentiful evacuation, and sometimes with great pain and griping. Calomel, and other mercurial preparations, have been judged to quicken the virtue of purgative medicines, and to render their operation far more certain. This power of mercury has not been satisfactorily confirmed to me by experience ; perhaps because I have not used it often enough, or not in cases which admitted any relief. Clysters seem to do very little good, except those prepared from tobacco ; the smoke of which is commodiously thrown up this way by such an instrument, as is now commonly used by gardeners to fumigate trees in order to free them from insects.* It is not unlike the wooden one described in Heister's Surgery ; but it should be made of brass, and, instead of a pipe at the top, to which in Heister's the mouth is to be applied, there should be a conical brass tube, the top of which should be so small as to enter an inch at least into any common cham- ber bellows. This is much more commodious than when the tube is made to screw on to the pipe of a pair of bellows made on purpose for it: for then the bellows must always be carried with it; whereas any common pair may be used with the conical tube. The tobacco is very conveniently lighted by a piece of touch-paper. The smoke of tobacco thus conveyed into the rectum acts very powerfully in controlling the irregular motion of the intestines, and in forcing them strongly to empty their contents in the natural manner. Such an enema has sometimes succeeded the first time of using it, and some- times not until it had been repeated every four hours for a whole day: and in too many cases it has totally failed of doing any good. Possibly some sorts of tobacco may possess this virtue in a stronger degree than others, which by future experience may be ascertained. Where the proper instrument for giving the smoke cannot be had, there an infusion of tobacco may be used, made of twelve ounces of •Among the remedies for the ileus, Hippocrates mentions inflating t'le intestines. ♦u(T«r £*Aim/Ti*>» trutu, mi a bad taste in the mouth, offensive breath, cough, shortness of breath, itching of the nose, pains of the stomach, sickness, loss of appetite, voraciousness, wasting of the flesh, tenesmus, itching of the funda- ment towards night, and lastly, skins and slime in the stools. The tape, or flat worms, are the most injurious to health : the round worms and ascarides would sometimes hardly be suspected, if they were not discovered by the itching of the fundament, or did not ap- pear among the feces. I have seen a tape worm of the length of four ells, which came away at once. Separate joints of it are often void- ed alive. The round worms will come up alive into the mouth, and I have known them live two or three days after they were come out. In two instances, which have occurred to me, there was ground to suspect that the jointed tape worm had occasioned epileptic fits, mad- ness, and idiotcy. We have the misfortune to have innumerable remedies for the worms ; this being pretty generally a sure sign, that we have not one, upon which we can with certainty depend. Spirit of turpentine, oil, infusions of tobacco, and mercurials, which are such deadly poisons to many small animals, out of the body, have been thrown up in clys- ters without destroying the ascarides; they, and probably the other worms, being so defended by the mucus, in which they lie, that they are secure from the action of any noxious powders, or liquors. Until therefore the reputation of a specific for worms be better established in some of the many medicines which lay claim to it, nothing better can be done, than giving purging medicines of any kind which are best borne, and can be repeated without creating too great a degree of loathing. Bitters either joined with these, or in the intermediate times, may be useful, not that I have any reason to believe them hurtful to worms, but because they will help to restore the disorder- ed stomach and bowels to their natural strength. A pint of water with as much common salt as could be dissolved in it, has more than once been of singular use in expelling worms from the intestines.* CHAPTER LX. Lymphatics Glandulce. Blistering plasters are apt to make the neighbouring lymphatic glands swell, but this swelling has generally soon disappeared. After a blister the whole arm of one person continued to be swelled for a long time ; probably from some obstruction of the lymphatic vessels. A blister applied to the head has in several persons so obstructed the course of the lymph, that the whole forehead has been enormously swelled for a day or two. This swelling has gradually descended to the cheeks, and chin, and neck, and then disappeared. * See .Med. Trans., vol. i., p. 54. MAMMAE. 125 In an old woman, who seemed otherwise healthy, and in particu- lar had no disease of the breast, the lymphatic glands under the arms began to swell, and be obstructed, in consequence of which the whole arm and hand swelled to an enormous size without pitting, and after a little while she died. Likewise in a young man the face, and head, and breast were greatly swollen without pitting, the veins of the breast were varicous ; he had pains in his jaws, was sleepless, short breathed, could hardly bear to lie down, and after a few months died. CHAPTER LXI. Mammae. It has been known that milk has continued to fill one or both the breasts of a woman for four months, for five, for six, for seven, and even for twelve months after she had weaned her child. In a nurse, who was seized with the small-pox, the milk went away just at the height of the distemper, and returned copiously as soon as that was over. A woman in her fortieth year began to feel her breasts swell: they were soon after filled with milk, which ran out for three months: as soon as this stopped, she became pregnant: she had no child before for six years. It often happens to lying-in women, and it may happen to any other, that the breast inflames, and comes to suppuration : the adi- pose membrane seems to be the seat of this inflammation, the glan- dular part being very little concerned in it; and it is of no more consequence in this part, than such a sore would be in any other part of the body. A swelling of the breasts with little or no pain, except a sense of tension, attends pregnancy, and sometimes the regular menstrual discharge, as well as its obstructions, and various other irregulari- ties. The breasts of women are subject also to pain, either with or without a swelling, which often lasts for a long time, and yet is of as little consequence as their swelling, while they continue free from any hard lump. A slight blow on one of the breasts has occa- sioned a pain, which lasted at least ten years without the appearance of its ever coming to any further mischief. In a great variety of in- stances, pain has come on without any external cause, and has lasted in some above twelve years, and then has gone off spontaneously : great care should be taken, that this pain be not increased by the pressure and tightness of the stays : a gentle opening medicine may now and then be advisable in such a case. It seldom happens that pain does not occasion a general fulness of the breast, but if there be no hardness, which denotes a beginning scirrhus, the swelling and pain have often been considerable without any mischief ensuing. A serous or bloody oozing from the nipple, has been the forerun- ner of a cancer ; and it has likewise often appeared, and the nipple 126 HEBERDEN'S COMMENTARIES- has been for many years drawn in, without making any further pro- gress to that dreadful evil. A scirrhus, or hard lump, though ever so small, formed in the breast, may justly cause some apprehension of ill consequences ; for I have never known a cancer come without being preceded by this: nevertheless I have in many instances re- marked that this has been formed without being followed by a can- cer ; especially if there have been no previous pain, swelling or dis- charge from the nipple. For a lump has frequently been felt by ac- cident in the breast, and might perhaps have been there a consider- able time before it was discovered, the breast being in every other respect in its natural state. While a small scirrhus in the breast continues quiet, it is best to forbear all external applications, and ad- ditional coverings to keep the breast warmer than usual; nor can I recommend any internal medicines ; an exact diet seems to answer all reasonable purposes. Nature will sometimes disperse a scirrhous gland in the breast, as I have several times observed, and particu- larly in one woman, where the tumour seemed to tend to so much malignity, that it was thought advisable to cut it out: some accidental circumstances delayed the operation for sometime ; and in the mean- while the swelling of the breast became less, and softer, and con- tinued to do so till it totally vanished. These however must be acknowledged to be rare cases ; but it is by no means unusual for a scirrhous swelling of the breasts neither to grow, nor to be painful for many years, especially if it were formed, as happens in a few women, before the age of thirty. The most usual, and the most dangerous time for the coming of a tumonr in the breast, is near, or after, the fortieth year of life ; yet in a woman of seventy it has oc- casioned neither pain, nor inconvenience for seven years, and seemed to have no connexion at last with the distemper of which she died. I have noted one man, in whose breast a scirrhous lump had arisen exactly the same with what is so common in the other sex. In an- other the breast became cancerous, and was successfully cut off. As soon as a hard tumour in this part begins to be uneasy, and to spread with pricking pains (in which state it has continued for several years before it has broken), many both external and internal medicines have been recommended to check its progress, and to disperse it. I have not seen much reason to confide in any of the means, which are supposed to have the virtue of resolving such a tumour, after having first soothed it to a state of indolence ; though in two or three instances as I have noted, the extract of hemlock has had the repu- tation, and perhaps justly, of effecting this. But then it has undenia- bly failed in so many others, that it is in my judgment not worth any body's while to waste, in making a trial of it, any of that time, which is so precious after the tumour has once begun to make advances towards ulceration. The insignificant pain of cuttino- it out while it is small, and the prospect of its healing readily on account of the smallness of the wound, and of the health not being yet much hurt should determine every one to the operation at this time. If the breast be curable, this, I am persuaded, will be the best cure • and MENSTRUA. 127 supposing that the mischief is not local, but that the whole body is infected either with an hereditary, or an acquired cancerous taint, I am not aware that the distemper would either more certainly, more rapidly, or more painfully put an end to life, for having made this most promising effort to elude its power. If the want of resolution in the patient to have the scirrhus taken out, or the delay occasioned by the trial of various specifics, which had promised much, and performed nothing, have suffered the hard- ness gradually to occupy the whole breast, and to ulcerate, with a great increase of pain in the part, and flying pains over the whole body, and hectic fever, and loss of appetite, of flesh, and of strength (at which state it may arrive in a few years, or in a few months) what is then to be done ? Now even in this state, if the schirri have not spread too far under the arm-pit to be all cut out, the time of the operation is indeed almost over, but not entirely ; for in these almost hopeless circumstances I have known it performed with success. It can be no wonder, when done so late, that the operation often fails, and that the wound should either never heal, or that fresh schirri should arise after it has been healed ; still, there will be some advan- tages in giving a little respite to the patient, and her attendants, from the offensiveness of a foul ulcer, by removing at once the putrid mass. Where the cancer is spread deeply under the arm, and the whole arm is swelled from the obstruction of the lymphatic glands, with loss of appetite, and strength, and shortness of breath, and every sign of inevitable death, all which then remains to be done, is to keep the ulcer with proper dressings (by washing it with water impregnated with fixed air, or by the application of a carrot poultice, in which this air abounds), as clean, and as quiet, as may be ; and to soothe the pains, and procure rest with as much opium as is necessary for these purposes. The degree of pain attending a cancer is extremely various; in some it appears to be great, and in others but slight and incon- siderable. CHAPTER LXII. Menstrua. The regular and natural state of the menstrual flux in women is well known to be intimately connected with their health. They seldom suffer much from any distemper without experiencing some deviations in this particular from the orderly course of nature ; and the irregularities of this evacuation, if they continue long, except in pregnancy, will most commonly have bad effects upon the general health ; but these irregularities are perhaps oftener a sign, than the cause of other distempers. The proper time of the first appearance of the menstrua, is from the age of twelve years to fifteen. Some show of them has been known in girls of eight or nine years, and even of five years; but I 128 HEBERDEN'S COMMENTARIES. never knew an instance of their continuing to return regularly, when they began sooner than the tenth year of life. These very early ap- pearances have not been attended with any ill consequences, and re- quired only a little rest and patience. When the catamenia begin first to flow at the proper time, it hap- pens to many young women, that for the first year or two they will not go on to observe their exact periods, without either exceeding, or falling short of the just quantity : in this case, and likewise where they delay to come on for one or two years beyond the usual time, it is better not to be too hasty in prescribing medicines ; for as the strength of the body increases, nature will most usually set all such little anomalies to right, where there is no other distemper, and in the meantime the constitution will suffer no harm. The case is very different after women are come to their full growth, and strength ; for every function of life will suffer, and often in a violent manner, from great disorders of this evacuation ; yet nature has allowed some latitude, so that no inconvenience will arise from the catamenia coming a week sooner or later, staying a day less or more : all which we find by experience to be very consistent with good health. There are constitutions, in which not only miscarriages, difficult births, and frequent lyings-in ; but even terror, uneasiness of mind, and moderate exercise, occasion such a loss of uterine blood, as hath brought on great pains in the head, back, and bowels, and a danger- ous weakness. Sometimes without any apparent cause the menses have exceeded the healthy limits, by returning too often, or by con- tinuing to flow too long, or in too great abundance. These hemor- rhages have been so lasting as to have continued for many months together ; or so profuse, as by their abundance to have threatened immediate death. But these cases, where pregnancy was not con- cerned, have been usually more alarming than dangerous ; for among the many instances of excessive floodings which I have known, I have remarked only two, who, without being pregnant, have bled till they were exhausted, and died. The menstrual discharge gradually lessens between the fortieth aifti fiftieth year ; and sometimes misses for two or three periods, and after giving warning in this manner for a year or two, it then totally ceases. This seems to be the most natural way of its going off. But it very commonly happens, that at this time the uterine flux, instead of lessening, returns more frequently, and with more violence ; so that, except in cases of pregnancy, the greatest uterine hemorrhages have been observed at the time when nature is about ceasing to sup- ply them any longer. Young unmarried women sometimes have their monthly evacua- tion too often, and in too great quantity, but they are more subject to having it flow too sparingly, or to its not observing the regular periods, or to its being totally obstructed. The obstruction of the catamenia has been imputed by the persons themselves to wetting their feet at the time of this flux, to terror and MENSTRUA. 129 to frequent venesections. The injury done by difficult births more frequently occasions floodings, but has sometimes been followed by obstructions, especially if the milk continued to come into the breasts, which it has been known to do for several months after the child had been weaned, or though it had never sucked. Some distemper of the parts concerned, or a mal-conformation probably occasions irre- gularities or obstructions in some, especially in those, for such there are, who never experienced this evacuation. But perhaps obstruc- tions are most frequently owing to other antecedent disorders of the health, which by weakening the powers of life, and hindering the due nourishment of the body, reduces it to such an exhausted state, as to afford no supply for this evacuation. If a woman ever so regular in this particular happen to have a long fever, the menstrual discharge is almost always obstructed. So likewise consumptive women in the last stage of their distemper, cease to have their courses return, merely from their weak and exhausted condition. The effects which I have noted of suppressed menstruation, where it was not wholly dependent upon other disorders, are a weight and pain of the head, giddiness, a pale, and often bloated appearance of the face, flatulence, sickness, loss of appetite, indigestion, pains and a sense of fulness in the stomach and bowels, a swelling of the belly, which may be mistaken for pregnancy, pains of the breast, sides, back, and knees, swelling of the legs, loss of flesh, sleepiness, flush- ings, lassitude, fainting, melancholy, and the whole train of hysteric symptoms. The fluor albus has been a substitute for the menses, returning regularly for several months. The catamenia have in more uncommon cases been represented by a periodical bleeding of the nose, or by a vomiting of blood. Barrenness is an usual attendant upon any considerable deficiency of the menses ; yet I have known a woman have children, who was not above twice in the year in the way in which she should have been every month. The menstrua are often regular both as to time and quantity, but attended always with so much pain about the womb, as to occasion greater present misery, than any other irregularity, though with less hurtful consequences. This pain is most usually felt on the first day, and sometimes only for the first six hours, and is then so violent, as to make the persons keep their beds. In two or three instances I have known it not come on till the second day. A strangury has begun to be troublesome only on the last day. Pains of the head, limbs, back, and stomach, and particularly of the breasts, which are usually fuller at this time, together with sickness, and tenesmus, with all kind of hysteric evils, harass some women during the whole time of their menstruation. The catamenia in the ordinary course of nature cease between the fortieth and fiftieth year. A very few have lost them before the for- tieth (and one even before the thirtieth year of life) and yet enjoyed a good state of health afterwards, and have lived long. I have re- marked some, who have continued to have them till they were sixty years old. The) have become irregular in their time, and quantity, 17 130 HEIJEIt PEN'S COMMENTARIES. not only a few months, which is their common method, but even Cot a few years, before they have entirely disappeared ; and after ceasing three or four years have been known to return. The animal powers, while the menses are preparing to cease, seem to be greatly oppressed, and less able to keep any constitutional disorder under, or to exert themselves in shaking off any accidental illnesses, which therefore at this time are unusually troublesome, and less disposed to yield to their proper remedies ; so that any lurking gout, or madness, or cuta- neous diseases, have often taken the advantage of this weak state of the health, and have established a lasting tyranny. It is probable that the menstrua leave most women in a kindly manner, without exciting, or creating any disorders, which require the assistance of medicine. But some, upon the occasion of this great change in the animal economy, experience a variety of disor- ders. The most common is that of excessive floodings, attended sometimes with faintings, and convulsions, which though hardly ever immediately fatal, yet are always very alarming, and have been succeeded by dropsical swellings of the legs, of the abdomen, and of the whole body, and by a broken state of health, from which some are with great difficulty, and others never recovered. In the inter- vals of these discharges, the fluor albus often conspires to drain away the strength. Sleepiness, numbnesses, and palsies have followed, and probably have been occasioned by these weakening complaints. Cramps, and wandering pains, have been the next most general attendants upon this revolution in the health of women ; which may perhaps be the effect of a great loss of blood, where the catamenia have gone off in this manner ; for I have observed the same after other immoderate bleedings. Giddiness, and shortness of breath, belong also to this train of evils: but no part seems to suffer more than the stomach and bowels, whieh are apt to be afflicted at the time of this change with pains, sickness, loss of appetite, heartburn, flatulence, an uneasy sense of fulness, the tenesmus, and piles. Every hysteric symptom has joined itself with these disorders. The legs at this time of life are more peculiarly liable to inflammations, and ob- stinate ulcers. It is less to be wondered at that some constitutions sink under the greatness, or multiplicity of such evils, than that others, after struggling three or four years under several of the worst of them, have happily been restored, and their health perfectly established. Perhaps when the menstrua are fully over, after escaping, or sur- mounting these difficulties, the health of a female becomes firmer than ever, and she bids more fairly for long life, than a man of the same age. After the menses have disappeared at the natural time, and have seemed for many years to be totally gone, they have in some women returned beyond all expectation. This has happened at the sixtieth at the seventieth, and even at the eightieth year of life * and conse- quently after they had ceased for twenty or thirty years. In some of these they have observed their ordinary periods, as they had done in the earlier part of life ; but these unseasonable discharges have MENSTRUA. 131 oftener been irregular in their returns, too abundant in quantity, or joined with the fluor albus. The catamenia have in this manner re- turned and continued for seven years from no apparent cause, and without any evident injury to the health. This effect however most usually proceeds from some unnatural state of the womb ; and if these discharges be accompanied with great pains about the os pubis, the hips, and the loins ; and if in their intervals an offensive dis- coloured liquor drain away, they may justly be charged to an ulcer of the womb, which usually becomes cancerous, and incurable. A profuse uterine hemorrhage may be occasioned by something in the womb, which must be brought away before the bleeding can be restrained. In other cases the patient should be kept quiet and cool: the body must be rather inclining to purging than costiveness ; and liquors should be frequently sipped acidulated with lemon-juice, or acid of vitriol. A dram or two of syrup of poppies will often be of great use in soothing a restlessness or anxious state of mind, which increase the. malady. A very able and experienced physician* has proposed to me in consultation, the giving of one scruple of flowers of sulphur morning and night to such patients, where he judged it to be as useful, as in an immoderate flow of the piles. The Peru- vian bark is seldom omitted among the remedies prescribed in this case ; and other styptic substances, as alum, galls, and oak bark, are often joined with it, as well as given without it. If I were satisfied that experience of the good effects of such medicines had established their reputation, no reasoning, however specious, would make me hesitate to confide in them ; but if they be used because of the sense of astringency which they impart to the tongue, it maybe questioned whether this quality can afford us a reasonable expectation of their stopping the bleeding, in a part which they cannot reach till aftei they have been diluted by a great quantity of various liquids: and what degree of effectual stypticity can they then be supposed to pos- sess, when they are not readily able to restrain the bleeding of a small wound made by a leech, though the powder of these substances be immediately applied to the orifice ? I am cautious of opening a vein, for reasons given in the second volume of the Medical Transactions, Query the fourth.f One scruple of alum has been given every day with safety : but I remember to have seen one woman near fifty years old in a bad state of health, whose belly and pudenda were swelled in a remarkable manner, so as almost to close up the vagina, all which was attributed (perhaps without reason) to checking an uterine hemorrhage by taking daily ten grains of alum. Four grains of sac- charum Saturni stopped a profuse bleeding, as I was informed, in four hours ; but the violent and lasting colic which I saw occasioned by this preparation of lead, ought to make every one dread its use. Thirty drops of tinctura Saturnina had been taken every day by a woman for a like purpose, whom I afterwards saw labouring under a similar, though less violent, disorder of the bowels. Steel waters have • Sir Edward Wilmot. 1 Sec Appendix. 132 HEBERDEN'S COMMENTARIES. in several instances increased the hemorrhage. Camomile flowers have done the same : and so likewise has lying down; contrarily to what I should have supposed. The opposite disorder to flooding, namely, where the catamenia are too sparing, or totally obstructed, may be occasioned, as was be- fore observed, by a variety of other complaints, the remedies of which will be the likeliest means of rectifying all the ailments dependent upon them. But where there appears no ill health, except what is the effect, rather than the cause of the partial or total obstruction, there stimulating, bitter, aloetic, and chalybeate medicines are what physicians from general experience seem to have rested in ; various forms of which are to be found in all pharmacopoeias. The black hellebore root claims some specific virtue as an emmenagogue, of which in my practice I have never met with any decisive proof. Camomile flowers undoubtedly possess it with relation to particular women ; for I have known more than one, in whom they constantly brought on some degree of an uterine hemorrhage, at whatever time of the month they were taken. Warm bathing, putting the feet in warm water, and sitting over its vapour for half an hour every day, have been used successfully. Electrifying, when employed for other purposes, has frequently brought on the menses before their time. But there are too many cases in which all these means have been found ineffectual. The pains, which several women experience during some part of the menstrual flux, are safely mitigated with opium ; and such per- sons should always have in readiness half a grain or a grain of opium, to be taken as soon as the pain comes on, and to be repeated once or twice if the pain require, at the distance of half an hour. This has been very frequently given without checking, or in any manner deranging this evacuation. To those, whose stomach will not bear opium, it has been given as safely in a clyster. The tincture of opium has not appeared to be without some effect, when only rubbed in by a warm hand over the abdomen. Warm bathing, sitting over the steam of warm water a few mornings before the expected return of the cata- menia, Bath waters, both externally and internally, have all been employed against this complaint, and with advantage. At the time of life, when it is according to the course of nature that the menstrual flux should entirely cease, if it go off gradually and without any troublesome symptoms, which it most frequently does, no medicines will be wanted, nature herself being fully sufficient to bring about this revolution without any tumult or commotion. How- ever, some attention may be useful in keeping the body from any tendency to costiveness, by taking occasionally a little lenitive elec- tuary, or some purging water. If the menses leave a woman very abruptly, and either from this cause, or from any other, there should come on at this time vertigos, sleepiness, numbnesses, or pains of the head, with a sense of fulness, the taking away of six ounces of blood by cupping once a month, as long as these complaints remained, has been experienced with success. Whatever other disorders may MORBILLI. 133 chance to show themselves, they must be treated with their usual remedies. In constitutions, which have been subject to cutaneous diseases, or which may be judged to be in danger from palsies, or some hereditary cancerous taint, an issue may be advisable ; which in other cases, as far as I have observed, may very safely be omitted. A return of the menstrual flux to old women, after having left them for some years, may either be excessive, or it may be a symptom of an ulcered, or cancerous womb ; and then the proper remedies for these ails must be employed: but if it continued to make its visits in a regular manner, as it has happened to some women, and the health appear in no respect to suffer, such persons will stand in need of no assistance from physicians. CHAPTER LXIII. Morbilli. I purpose first to give a history of the measles in a single patient, who had a regular and middling sort, and in whom, on account of the fairness of the skin, it was easy to observe with preciseness the appearance and disappearance of the eruption: after which I will relate the varieties, which I have noted in a considerable number ot other patients. On the first day The symptoms were very slight shiverings, a failure of appetite, some degree of sickness, a quickness of pulse, a dry cough, no sneez- ing, no tears, nor redness of the eyelids, a very little thirst, and pains in the limbs. . 2d. The night was quiet without any great complaint, the appe- tite still fails, and the cough and pulse are as before. 3d. This day all is much the same as yesterday. 4th. A faint eruption is to be seen by attentive looking upon the face • red spots are much more visible about the throat. The fever, restlessness, and want of appetite, are increased. The cough is rather less. The eyes are less impatient of light. There is no vomiting. The face burns, and is unusually flushed. 5th Faintly red spots are sprinkled over the chin, and (at a greater distance from one another) over the rest of the face. The spots are of an irregular figure, and are much redder about the throat and breast. The fever and cough remain. There is yet no appearance of the eruption on the hands and arms. . 6th. The spots of the face rise a little above the skin, so as to afford a perceivable roughness to the touch, and are visibly formed of many minute heads much less than a millet seed. On this day the eruption begins to appear on the arms. The fever, and restlessness, and impatience, are considerably increased. The cough is very trou- blesome, but without any difficulty of breathing. The eyes are weak, the eyelids are swelled. There is a total loathing ot all food. To- 134 HEBERDEN'S COMMENTARIES. wards evening the symptoms grow worse, and with some oppression of the breath. The spots in the face are of a lively red. Yesterday the menses came on before their regular time, and lasted only twenty- four hours. . ... 7th. Bleeding yesterday gave some relief. The night was a little quieter ; but the fever and anxiety are very little abated. The erup- tion in the face is paler. The skin begins to itch in a troublesome manner. 8th. The symptoms are much abated, and the appetite begins to return. The eruption is more faint. The languor and fever are now and then much complained of. 9th. The night was tolerably quiet, and the patient is now -a little revived ; but still there are intervals of fever, and uneasiness, and lowness, which are much relieved by a repetition of bleeding. 10th. The night was very good. The eruption has totally disap- peared, and hardly any fever remains. 11th. Some cough still remains. . 12th. The sleep and appetite are returned, but the cough still re- mains ; and so it continued to do for three or four days more: bleed- ing much weakened it, and in a few days more it went entirely away. I shall now proceed to relate some diversities in the symptoms, which have attended the several stages of the measles, collected from a considerable number of patients. Some have had weak and watery eyes one or two days before the eruption, and sometimes the same sharp humour has irritated the nostrils, and occasioned sneezing. The cough most usually has come on two or three days, before the eruption; but it has been known to precede the measles seven or eight days, and it generally did so in the year 1753, when they were remarkably epidemical. Pains of the throat and head and back, have not been unusual in this preparatory stage. One person in particular had a most excru- ciating pain in the back, which continued a day or two after the eruption. Sickness and vomiting as well as want of appetite, have come on at the beginning, and lasted till the middle, or decline of the distemper. Some 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. The longer the preparatory symptoms continued, and the worse they were, so much the less mild has the distemper proved. The first day of the eruption. In one or two patients I have seen the -eruption appear upon the arms on the first day, a few hours after its having been observed on the face and neck. But it so seldom happens that the arms and hands show any mark of the distemper before the second day of its being visible on the face, that possibly in those instances the erup- tion on the face might have been earlier than it was taken notice of. In one patient no cough nor sneezing was complained of till the day MORBILLI. 135 of the eruption. The appearance of this distemper does not at all mitigate the symptoms, as it does in the small-pox. One patient was seized with a spitting on this day, which continued to teaze him for forty-eight hours, without suffering him to rest at all by day, or to sleep by night; the cough in the meantime almost ceased, and all the other symptoms were as mild, as in a favourable sort of the measles. 2d. I have scarcely ever observed the eruption on the hands and arms fail of being perceived in the course of this day; and where it has been supposed to have been deferred a day longer, it is most probable that there was an error in dating the beginning of the erup- tion. Once or twice the distemper has been observed never to have reached the arms, which throughout the whole of it showed none of the usual spots. On this day the measles appear in full vigour upon the face, but without any relief of thq symptoms, which are often rather aggravated, and a diarrhoea has been joined to them, but without any danger. The nose has bled about this time, and the eyelids have been so swelled, that for twenty-four hours they could not be opened. 3d. Now the eruption usually appears very lively on the other parts, but is a little deadened upon the face ; yet in several the marks on the face have been at this time of as bright a red as ever. In others I have observed them to disappear entirely on this day, and all the other symptoms likewise to retreat. However, the cough and fever most commonly continue the same ; some patients have thought them a little better, others a little worse. Where the eyes have been very watery, and the eyelids red, they have still remained so to this time ; and I have noted a very troublesome and constant sneezing, which first came on upon this day. A child five years old became comatose the third day of the eruption, and died the next. 4th. The spots in most patients become of a much paler colour in the face, and begin to grow fainter in the breast and arms of some ; in others the arms are of as high a colour as ever: yet in more per- sons than one I have observed no diminution of the colour even in the face on this day. Those, who have shown the least remains of the eruption at this time (and some have shown hardly any) have ap- peared the best ; and in those, where it was still in undiminished vigour, the cough and fever have been the worst. The cough in several is very sensibly abated on this day; others find both cough and fever as bad as ever. The eyes seldom continue to water any longer, except where they have been so hurt by this illness, as to continue weak for a long time after. The sneezing has lasted till this time : but this has very rarely happened. The face now begins to be branny and itch, which itching is propagated over the whole body, so as to be the chief, or only complaint. The catamenia have appeared on this day before their regular time. f>th. The marks are very pale both in the face and arms, though perceivable in some : in others they are quite gone, the appetite re- turns, and the patients seem well. Those patients have betn the 136 HEBERDEN'S COMMENTARIES. worst, in whom most of the eruption was still remaining. The cough in some is much better, in others it is quite gone ; but several are teazed with it a long time after the distemper is ended. The menses have made their appearance on this day, out of their regular course. 6th. The vestiges of the eruption have been still visible on the arms, and even in the faces of a few patients, with a considerable de- gree of cough, sneezing, hoarseness, and fever ; and I have once or twice seen some marks of the measles so late as on the tenth day of the eruption; but on the sixth day most patients are tolerably well recovered, except in those unfortunate cases, in which the fever, in- stead of abating, begins at this time to increase, and continues to do so, until it have destroyed the patient. In others, who escape this immediate danger, the lungs are sometimes so injured by this dis- temper, that a lasting cough succeeds; and sometimes a pulmonary consumption. Weak eyes, inflamed eyelids, glandular tumours, and many other scrofulous appearances have followed the measles ; whether they were formed by them, or, the seeds being before in the constitution, were only excited by this distemper; or possibly the appearance of scrofulous symptoms was wholly owing to other causes, and would have come on at this time though there had been no measles. Bleeding may be used at any time of the measles, and is al- ways beneficial where the symptoms are very distressing, particularly if there is an oppression of the breath, to which every stage of this distemper is liable. Bleeding, together with such medicines as the occasional symptoms would require in any other fever, is the whole of the medical care requisite in the measles. The flowing of the menses ought to be no objection to the opening a vein, if the cough and shortness of breath make it otherwise advisable. I never saw any bad consequences from bleeding a woman in these circum- stances ; but the greatest danger might attend the omitting to do it in a violent cough, or oppression of the breath. The measles are far less dangerous to pregnant women, than the small-pox. I have attended several, who were greatly harassed by the violence of all the usual symptoms in this illness, but I never knew it to make one woman miscarry, or be in more danger on ac- count of the pregnancy. Is not 'this distemper worse in proportion to the quantity of erup- tion, as in the small-pox? The preparatory symptoms of the measles have appeared thirteen days after the infection had probably been received. In two others there was the greatest reason to judge, that they began to come on fourteen days after the time of infection. In four others the infec- tion seemed not to have lain dormant above ten days. An infant sucked a nurse till the measles appeared upon her and then was taken away, and escaped catching the distemper-'is it therefore like the small-pox, not infectious in its first stage ? o'r did the incapacity of this child's receiving the measles at that time arise from some other cause ? NARIUM HEMORRHAGIA — NAUSEA. 137 CHAPTER LXIV. JVarium Hcemorrhagia. A spontaneous bleeding of the nose more particularly belongs either to children, or to such as have past the meridian of life. In children it seldom comes to any excess ; but in adults will continue so long, or with such violence, that many pounds of blood will be lost, or the person faint away. Weakly children seem more subject to it than the strong ; and among adults, beside its being an usual attendant upon the diseases of the liver in hard-drinkers, it often accompanies the gout, head- ache, giddiness, numbnesses, a broken state of the health, and threatenings of a palsy or apoplexy. In a few extraordinary cases I have known it come on a little be- fore the catamenia, and continue till after they were over: in some females it has seemed to supply the place of the menstrual discharge; on the other hand, that discharge has proved, as long as it continued, an effectual stop to a bleeding of the nose, in some, who were never free from it for so many days together at any other time. The loss of blood by the nostrils is perhaps a symptom of some internal morbid cause, rather than a remedy ; for it has not appeared to me to be of any certain use in those distempers with which it is joined, and therefore it is not a desirable evacuation. But, on the other hand, it is far from being a constant sign of any great mis- chief either present or impending ; for I have known it continue in persons of an advanced age for many years, consistently with very tolerable health. An old headache has been judged to be relieved by a bleeding of the nose ; but this is made doubtful by its having been a companion in other cases of headaches, and various disorders of the head, without affording them any mitigation. Nothing so effectually stops a profuse bleeding of this part, as a compress put up the nose, when it is possible to apply it to the mouth of the bleeding vessel; but where this cannot be done, I know no other method of cure, than what is mentioned in the Medi- cal Transactions, vol. ii., Query 4.* In habitual bleedings of the nose, a moderate dose of some purging salt has been given twice or three times a week with success. CHAPTER LXV. Nausea.\ Pregnancy, the gout, hard drinking, hypochondriac disorders, gid- diness, violent headaches, a cough, and particularly the hooping- cou-h, worms, a stone in the kidneys, and irregularities of the men- strua: all these causes, beside blows on head, and many fevers, and * >^ec Appendix. | s.c chapter xcix , de Vomitu. IS 138 HEBERDEN'S COMMENTARIES. the improper quality or quantity of the food, are apt to disorder the stomach, and to bring on a nauseating and sickness ; which is some- times preceded by a large quantity of water filling the mouth, the morning is the time when this sickness is commonly greatest (the nerves of the stomach, like all the others, seeming to be weakest in the morning); it will likewise come on sometimes about three hours after dinner. As this complaint is owing to such a variety of causes, it might easily be expected, as it is found to happen, that the same method of treating it will not always have the same success. An emetic, lying down, aromatic and spirituous medicines, a spontaneous or artificial purging, essential oils, and opium applied to the region of the stomach in the form of a plaster, or in the form of a liniment rubbed over the abdomen, the juice of lemons and salt of tartar drunk in the act of effervescence, infusions of common mint with or without tinctura opii, are sometimes, but not always employed with advantage in curing a nauseating fit. Infusions of camomile flowers will often relieve, by provoking a vomit, or only by strength- ening the stomach. In cases where it is a symptom dependent upon other disorders, its cure can only be effected by curing the principal malady. Bath waters drunk warm at the spring will remove several of the causes of sickness, and perform a lasting cure. CHAPTER LXVI. Oculorum Morbi. A weakness will sometimes attend the eyes, and make the wind, the fire, and reading very uneasy to them, though there appear no outward sign of any complaint. A greater degree of weakness is ac- companied with wateriness, or gumminess, where the tears are not supplied faster than they can dry into such a consistence. Strumous inflammations of the eyelids will long be troublesome without much affecting the eye, or making it impatient of the light or of reading. Where the eye itself is inflamed, all that part which should be white will have its vessels distended, and be red with blood : it feels as if it were full of dust or sand, and any degree of light is intolerable ; wind, heat, and dust, greatly aggravate the inflamma- tion. If the inflammation excite no great pain, while the eyes are kept dark it has continued for a year or longer, without ending in blind- ness ; though it will often leave films, or specks upon the eye, which hurt the sight if they be upon the cornea, and in any other part are a deformity. But dimness of sight, and blindness, will sometimes follow long and violent inflammations. I have known the eye fre- quently inflamed by the irritation of hairs growing in the internal part of the eyelid and pricking the eye ; the plucking out of these hairs is the certain and only cure. The eyes are subject to excessive and constant pain without any 0CUL0RUM MORBI. 139 outward appearances of disorder ; this has beenknownto last forseveral days ; and considerable pain at the bottom of the eye has continued for a year without any ill consequence ; but in general it is a state of the eye much to be dreaded. It has in six-and-thirty hours brought on a dimness of sight, which increased to blindness ; and it has by fits been troublesome for six years, and then blindness has come on. In many instances the sight has gradually become dim, and at last been totally lost, even within the space of a few days, probably from the optic nerves becoming paralytic. I have seen this occasioned by a preternatural mass being formed in the brain, which compressed the origin of those nerves. A giddiness has been the forerunner of blind- ness ; and so have the appearance of an iris round the candles, of flashes of fire of flies or threads floating in the air, which are black in the day time and of a fiery colour in the dark, of colours dancing before the eyes, and of a multiplication of the objects : but at other times all these confusions of vision have happened, and some of them have continued for ten years, yet the sight has not afterwards been hurt. A blindness will also come and go, lasting only a few hours, and this for several times, observing no certain periods ; unlike the nyc- talopia, which returns every night. The few blindesses of this sort, which I have known, have ceased at last, and left the eyes in their natural state. A blindness of the right eye has lasted for fourteen days, and then has suddenly passed to the left, where it fixed. A cataract is always preceded by a dimness, or blue cloudiness of objects, as if they were seen through gauze ; it is known by the pupil of the eye, instead of being black, becoming coloured. In affections of the eyes it is common to hear complaints of all objects appearing double ; I remember one who said they were quadruple. A gutta serena is known by an unusual dilatation of the pupil, and by its ceasing to contract or enlarge according to the different de- grees of light; it seems to be a palsy of the optic nerves. It is sometimes confined at first to one eye, but in the course of a few years is often extended to both. It comes with so little pain, and the sight of one eye is so little missed, that I have met with three or four persons, who by accident found out that one of their eyes was dark, of which in all probability they had lost the sight for some months before. This will happen both in the gutta serena and cataract. There is a dimness of sight, in which dark spots float before the eyes, or only half, or some part of all objects appear, which con- tinues for twenty or thirty minutes, and then is succeeded by a head- ache lasting for several hours, and joined sometimes with sickness. The disagreeableness and pain of these paroxysms are very consider- able, but as far as I have observed, the danger is nothing, though I have known some persons subject to them for twenty years. Their returns seem to observe no certain period, nor have 1 even been able 140 HEBERDEN'S COMMENTARIES. to guess at the immediate occasions of bringing them on, nor to discover any remedies either for their cure or relief, except that lying down appears to make the fit more tolerable, if not to shorten it. It is less in summer and warm climates, and age seems to lessen or cure it. Emetics have done no good ; it has even been suspected that they rather did harm. A violent giddiness has suddenly made a person presbyops, or long-sighted ;" and I have known two persons, who after having been unable to read without the help of convex glasses for several years found their sight come of itself to its natural state, so that they had no further occasion for spectacles. A giddiness has instantly brought on squinting, and made all objects appear double for twenty days, at the end of which the squinting and doubleness of objects ceased. The same thing happened to another every morning just after waking, and continued for some time. Many are persuaded that perpetual blisters weaken the sight. To which notion we may be tempted to pay very little regard, when we consider, that they are frequently applied with advantage in disor- ders of the eyes; and further, the little probability, which appears from all the known effects of cantharides, that they should particu- larly affect this part; and lastly, the great number of persons, who keep a blister for many years, or even a considerable part of their lives, without finding reason for suspecting any such mischief. But, on the other hand, we so often meet with those, who are confident upon repeated trials, that during the application of cantharides their eyes were growing weaker, and that they recovered upon the leaving the blisters off, that we can with difficulty account for the rise and prevalence of this opinion, without its having some real foundation in nature. Various parts of the eye are liable to ulcers and cancers. Weak and watery eyes may often be assisted by taking twice a week some purging water, and twice every day a wine-glass of the decoction or infusion of the bark. For this, and for some painful affections of the eyes, many washes are recommended, as white vitriol, flowers of zinc, tutty, saccharum. Saturni, spirit of wine, or milk and water. From the use of any of which ingredients I have never observed any such certain benefit, as to make me sure that a wash of pure water would not have been as useful. Strumous inflammations of the eyelids, where the eye itself is but little, or not at all affected, do not require bleeding; but where the eyes themselves are inflamed, nothing can be done without fre- quently taking away some blood. Of all the ways of doing which, I prefer leeches applied to the temples or behind the ears, and it is sometimes necessary to have recourse to them once or twice a week for several weeks. Cataplasms of conserve of roses, or of the pulp of boiled apples, or of bread and milk, put between two pieces of very fine lawn, and applied to the eyes at least every night, and if the pain and inflammation be considerable, both day and nio-ht re- newing them once in eight hours, are more serviceable than 'any 0CUL0RUM MORBI. Ill collyria. The purging waters, and bark, are perhaps the best inter- nal medicines both in this, and in all other painful maladies of the eyes. It is useful always at bed-time to anoint the margins of the eyelids with a little lard softened with water, and wherever the eyelids would otherwise be glued together in the morning; for if this be not prevented, and any force be used to pull them open, it will not fail to increase the soreness and pain. Setons, issues, and blisters, will often be necessary to assist in the cure, and to prevent the return of these diseases. In a gutta serena I have known issues, blisters, and all kinds of nervous medicines, strong sneezing powders, and a salivation, used without any success. Electrification is said to have been useful. A cataract admits no remedy, except that of the depression or ex- traction of the crystalline lens. It is observable that the ancients mixed opium with many of their topical medicines for the eyes ; if we reason upon any of its known powers and manners of acting, we should judge that as an acrid it would do no harm, and as a soporific it would do nothing at all in this way of application ; and probably should not judge amiss: for notwithstanding the prepossession in its favour from the authority of the ancients, this ingredient in collyria has sunk into disuse ; for which nothing can account, but a conviction of its inefficacy from repeated trials. Yet by some late experiments three drops of tincture of opium, applied every day to the eyes, have been thought useful in ophthalmies. Some oculists have succeeded in taken off films from the eyes with a knife, or with acrid applications. But this practice has been con- demned by many experienced and judicious surgeons, as too likely to excite an inflammation ; from which cause most of these films arise. Of the Nyctalopia, or Night-Blindness. A man about thirty years old had in the spring a tertian fever, for which he took too small a quantity of bark, so that the returns of it were weakened without being entirely removed. He therefore went into the cold-bath, and after bathing twice he felt no more of his fever. Three days after his last fit, being then on board of a ship in the river, he observed at sun-setting, that all objects began to look blue, which blueness gradually thickened into a cloud ; and not long after he became so blind, as hardly to perceive the light of a candle. The next morning about sun-rising his sight was restored as perfectly as ever. When the next night came on, he lost his sight again in the same manner; and this continued for twelve days and nights. He then came ashore, where the disorder of his eyes gradually abated, and in three days was entirely gone. A month after, he went on board of an- other ship, and after three days stay in it, the night-blindness returned as before, and lasted all the time of his remaining in the ship, which was nine nights. Hethenleftthe ship ;' and hisblindness did not return while he was upon land. Some little time afterwards,he went into another ship, in which he continued ten days, during which time the blind- ness returned only two nights, and never afterwards. 142 HEBERDEN'S COMMENTARIES. In the August following, he complained of loss of appetite, weak- ness, shortness of breath, and a cough : he fell away very fast, had frequent shiverings, pains in his loins, dysury, and vomitings; all which complaints increased upon him till the middle of November, when he died. . . He had formerly been employed in lead-works, and had twice lost the use of his hands, as is usual among the workers in this metal. CHAPTER LXVII. Ozcena, or a Suppuration of the Antrum Highmori. An oozing of matter from the cavity called antrum Highmorianum has continued for many months. The frequent injection of a liquor to cleanse it, was the only help which it seemed to admit. An in- fusion of camomile flowers is a very proper injection for this purpose. CHAPTER LXVIII. Palpitatio Cordis. Children sometimes bring with them into the world a preternatural palpitation of the heart, together with a mal-conformation of the breast, or other signs of great unhealthiness; and it is found, at all times of life, either following or joined with the asthma, hypochondriac and hysteric complaints, the gout, cutaneous diseases, too much care and business, flatulence, giddiness, faintings, languor, an urgent and trou- blesome micturition, and that general failure of the powers of life which is known by the name of a broken constitution. It has been attended with a perceptible noise, and rarely fails to make the pulse very irre- gular both in time and strength. The resemblance which this disorder bears to those complaints that are called nervous, and which are exasperated by bleeding, allows us very little hopes of relief from the use of this evacuation ; yet in one or two cases I have known it tried without any manifest hurt, and, as the patient supposed, with some benefit. Lying down also has in one person not increased, but rather eased the palpitation. In every other case, which I have observed, the bed has constantly ag- gravated this uneasy sensation, which has usually been worst of all just upon waking out of the first sleep. A full stomach is not easily borne by these patients. If we consider the rapid and irresistible progress of this complaint from bad to worse in some, and the very little disordering of the health which it occasions, together with the length of time which it continues in others, and the long truces, during which it is wholly suspended ; and lastly, that it will be excited in the healthiest per- sons by a mere thought of the mind, we must necessarily conclude PARALVSIS ET APOPLEXIA. 143 that it is owing to a variety of causes widely differing from one an- other in point of danger. Where it is curable, and requires a remedy, it must be found among the medicines which are proper in nervous maladies ; but a palpitation of the heart in many instances arises from causes too fatal to admit, or too frivolous to stand in need of any cure. CHAPTER LXIX. Paralysis et Apoplexia. Palsies and apoplexies are only different degrees of the same distemper. All sudden deaths are put down to the account of apo- plexies ; though some of them be unquestionably owing to ruptures of great blood-vessels, to suffocations from inundations of phlegm, or from the breaking of abscesses in the lungs, and other causes of immediate death, very different from those by which genuine apo- plexies are produced. A sudden, or rapid weakness in some of the muscles of voluntary motion, constitutes a palsy, and in this manner it most usually begins ; and a total loss of motion in every part of the body except the heart and organs of respiration, together with insensibility, is called an apoplexy; the cause of which is sometimes strong enough to put a stop to the motion even of the heart and lungs, and to occasion instant death. The power of moving in every part of the body by means of the muscles which obey the will, or by means of others the actions of which are involuntary; the various perceptions by the five external senses; and lastly, those mental powers named memory, imagina- tion, attention, and judgment, together with the passions of the mind ; all these seem to be exercised by the ministry of the nerves: and are impaired, disturbed, or destroyed, in proportion to any in- jury done to the brain, the spinal marrow, and nerves, not only by their peculiar diseases, of which we know little, but by contusions, wounds, ulcers, and distortions, and by many poisons of the intoxi- cating kind. The loss of the power of moving is the obvious and striking character of this disease, and what is chiefly meant by the name of a palsy ; and it sometimes happens that one or more limbs may become paralytic, with little or no perceivable defect in the office of those nerves on which the senses and operations of the mind depend. It is perhaps more rare, but by no means unknown, that from a paralytic shock one or more of the external senses have lost the exquisiteness of their perception, or the mind has become inattentive, forgetful, and stupid, with very little diminution of mus- cular strength : but it is most commonly found, that the bodily strength, and senses, and mind, all suffer from a considerable stroke of a palsy. Certain degrees of a paralytic debility of the senses and intellects, have had particular names assigned them, as carus, coma, lethargy. The reasoning faculty has in a palsy become dull and wild to such a degree as to amount to melancholy, idiotcy, and mad- ness. Likewise madness and palsy have returned alternately. An 144 IIKBERDEN 'S COMMENTARIES. epilepsy in some instances partakes so much of the palsy or apo- plexy, that it is hard to determine which symptoms are most predo- minant, and to which of these diseases the fit most properly belongs. The same is sometimes observable in the disease called St. Vitus s dance. Paralytic complaints chiefly attack those who are past the meri- dian of life, and are either sinking into the infirmities of age, or are broken with them and other disorders. But the middle ages are not secure, especially where persons are born of paralytic parents, or have impaired their health by fatigue, or intemperance. Children of all ages from infancy to puberty have sometimes lost the use of their limbs without any other manifest disposition to ill health ; but this has happened more frequently to the weakly, and to those whose constitutions had been shattered by convulsive fits, by epilepsies, and St. Vitus's dance. The gout disposes the subjects of it to apo- plexies, either by a general debilitating of the powers of life, or by some affinity between the causes of the two distempers. There ap- pears some tendency, though a more remote one, in hypochondriac and hysterical ails to be aggravated till the shattered state of the nerves become truly paralytic. Chronical rheumatisms, or imperfect gouts, after hanging on for many months, have deadened and per- fectly destroyed all ability to stir the limbs affected; but this species of palsy has gone no further ; so that the senses and faculties of the mind have still continued in their usual vigour. It is observable, that palsies arising from chronical rheumatisms, or imperfect gouts, affect chiefly the lower limbs ; but those arising from the colica Pic- tonum more usually affect only the arms and hands. So many women otherwise healthy have been struck with a loss of their limbs, and an imperfection of utterance, and sometimes with fatal apoplexies, in the pregnant and puerperal state, that I can have no doubt of their being liable to these mischiefs in consequence of these peculiar situations. One palsy, which had this origin, hardly went off in two years ; but from other palsies of the same kind most women have en- tirely recovered, and in no long time, and without any relapse. The child of a mother, who during her breeding became paralytic, was born in perfect health. Many palsies of "a small part, or of one half of the body, have begun with an apoplexy, or a sudden and total abolition of the strength and senses, which has continued from less than a minute to many hours; and the patients have been so far from having any previous notice, that for a few hours, or a few days before the fit, they have found themselves uncommonly well and cheerful. But more palsies have advanced gradually, without the patient's falling down in a motionless and senseless state : and the approach of some has not hindered the person from remaining in the full possession of his understanding. A faltering and inarticulation of the voice drow- siness, forgetfulness, a slight delirium, a dimness of sight, or objects appearing double, trembling, a numbness gradually propagated to the head, a frequent yawning, weakness, distortion of the mouth a PARALYSIS et apoplexia. 145 palpitation, a disposition to faint; some, or most of these, have pre- ceded a palsy for a few minutes, or for some hours, or even for a few days ; and a weakness of a limb, or of one side, has been many months, or a few years, gradually increasing to a perfect loss of one side, or a hemiplegia. I have known a sleepiness and duplicity of objects with violent pains and tightness of the head for two days, then the senses and voice were lost, and on the third the man ex- pired. A numbness of the hand has come on the first day, on the second a faltering of the voice, and a palsy on the third. Similar instances are very common. The notices of an approaching fit have come and gone for several hours, as if there were a struggle between the disease and the constitution, before these threatenings have either wholly disappeared, or ended in palsy. Violent pains of the head, or a weight, and tightness, as if it were surrounded with a stiff ban- dage, giddiness, numbnesses, noises in the ears, and a frequent bleeding of the nose in adults or old persons, may probably pro- ceed from a slight degree of some paralytic cause; but they have continued for a considerable part of a man's life without being joined by any other mischief, and therefore are by no means reasons for much alarm, though they may justify the use of some precautions. Flashes of fire, or dark spots before the eyes, have preceded some apoplexies, but have for the most part no relation to them, being merely disorders of the eyes, and not proceeding from any general affection of the nerves. A palsy of the lower limbs has often been preceded by a great pain in the loins. Where the origin of all the nerves is injured, all their functions are consequently affected. In practice there occur instances of all possible varieties in paralytic affections of the nerves, from the numbness and weakness of a single joint of one of the fingers, to a total abolition of sense and motion throughout the whole body, or a fatal apoplexy ; and there is an infinity of intermediate degrees be- tween these two extremes. The muscles of the lower lip have been paralytic, and no other part of the body. It is not very uncommon to see this happen to the muscles of one or both the eyelids ; and a still more frequent palsy is that of the organs of speech, taking away all power of speaking articulately, or of speaking at all; and that also of the muscles of one side of the face, which suffers that corner of the mouth to sink lower than the other, and hinders the meat from being easily moved about in mastication, and sometimes lets the spittle and drink run out of the mouth. In one person a palsy of the right side of the face was attended with an exquisite pain be- hind the right ear; and in another a like pain behind the left ear was joined with a palsy of the left side of the face. The paralytic weakness has been confined to the muscles of deglutition, or to those of the tongue. One arm, one leg, a hand, or a single finger, have been the only parts affected. The muscles of the thighs and legs have frequently been the seat of the distemper, having lost all power of contraction, and so have at the same time the sphincters of the bladder and rectum, so that the urine and feces could not be re- 19 146 HEBERDEN'S COMMENTARIES. tained : in other instances of a palsy of the lower limbs, these ex- crements have been with difficulty expelled, the muscles serving to their expulsion having been more weakened than the sphincters. Scarcely any species of palsy is more common than the hemiplegia, in which the motion of one side is impaired or lost, from the fore- head to the extremity of the foot. The right and left side are equally disposed to be paralytic ; at least it appeared so in a great number of patients, in whom a particular attention was paid to this circum- stance. The same paralytic cause seems determinable by slight and unimportant accidents to fix upon one side, rather than another; for I have noted eight persons, who had recovered from a hemiplegia, and in a subsequent attack were struck on the opposite side. Though paralytic persons often find the perception of the five senses dull and confused, yet I attended one, whose sense of smell- ing, instead of being impaired, became so exquisite, as to furnish perpetual occasions of disgust and uneasiness, and from some very ridiculous'causes. A lethargy in another patient was succeeded by a sleeplessness, and at the same time all the external senses became more acute : but I do not remember any other instances of a palsy, in which the functions dependent upon the nerves (if at all affected) were not altered for the worse; except that the appetite has in some cases become more keen. No symptom is more common in this dis- ease, than a numbness, or some degree of a loss of feeling; and yet a total loss of it is extremely rare. Out of the very great number of palsies, which I have seen, there have been only seven in which the sense of feeling was annihilated. In three of these the feeling was totally gone, while some motion remained ; and in another it did not return, though some degree of motion was restored. In a fifth the feeling began to return in half a year. In the two others neither the feeling, nor motion, were ever, as far a's I knew, retrieved.* Of all the powers of the mind, the memory, and the government of the passions, appear to be the most weakened in palsies, though it may be doubted whether they be more affected than the imagina- tion or judgment. There are perpetual occasions for showing the loss of memory, and that childish impotence of mind, which suffers a man to fall into tears, or to be transported with joy and anger for frivolous causes ; but the exercise of the imagination and judgment are more seldom called for, and therefore their usual powers will not be so readily missed. The faculties of the mind are enfeebled in all possible degrees, as well as those of the body. When a person therefore has been struck on the left side, and has at the same time lost his voice, there is no certainty of his being able to signify his feelings, or his wants, by writing. They, who have been put upon this, have sometimes been able to do it, though in a confused man- ner ; and the same person on different days would either write intel- ligibly, or make only an illegible scrawl. The shock upon the un- * Ramazzini mentions a case of palsy in which one leg had lost all power of motion, but preserved its sense of feeling; and the other leg was deprived of itc feeling but re- tained its motion. — Be Morb. Artif., p. 286. — E. PARALYSIS ET APOPLEXIA. 147 derstanding has been such, that it was not possible to make the patients mark upon a slate yes or no, or point to them when written, so as to make a right answer to any question. The inability to speak is owing sometimes not to the paralytic state of the organs of speech only, but to the utter loss of the knowledge of language, and letters; which some have quickly regained and others have recovered by slow degrees, getting the use of the smaller words first, and being frequently unable to find the word they want, and using another for it of a quite different meaning, as if it were a language which they had once known, but by long disuse had almost forgotten. After an apo- plectic state for several days (owing to a blow upon the head) one person was forced to take some pains in order to learn again to write, having lost the ideas of all the letters except the initials of his two names. A palsied arm has been accompanied in many persons with an ex- cessive pain about the shoulder, so that they could hardly be per- suaded that there was no fracture nor dislocation. Costiveness is an attendant upon this distemper, where the stools do not come away involuntarily; but it is usually accompanied with an uncommon flow of urine. A paralytic affection of one side has appeared, upon open- ing the head, to have been occasioned in some by a hurt, or some preternatural state of the brain on the same side, and on the opposite side in others. The general rule in a hemiplegia is, that if the patient recover, the motion of the leg begins first to be gained, and afterwards that of the arms ; but to this rule there are many exceptions. In a slight palsy of the tongue, it has felt as if it had been scalded. The apo- plectic fit rarely goes off without leaving some part paralytic ; how- ever it is not often that an apoplexy or palsy proves fatal in the first attack ; but whoever has suffered from either of them, the same per- son is more likely to be affected again; and the more frequently the fits have returned, the sooner and more certainly is a fresh attack to be expected. Yet it has happened, that persons have been restored from a strong attack of a hemiplegia, and have had no relapse in fourteen, eighteen, or twenty years. It must be owned indeed that such cases are, rare, and that a violent degree of palsy, how well soever it may seem to have been cured, seldom fails to be repeated within the space of a few years, and it has frequently returned in a few months. It is not uncommon to recover from a palsy of a small part, as of one side of the face, without any ill effects upon the health ; and, though it happen in youth, without experiencing any return to ex- treme old age. After the first considerable shock there are often repetitions of smaller fits, which, by coming in the night, or during a nap, are not observed, but may be conjectured by several circum- stances, and particularly by all the effects of former attacks becoming much worse either suddenly, or in a few hours. There is particular danger of these repetitions for several days after a great fit, till the constitution have a little recovered from the violence which it has 148 HEBERDEN'S COMMENTARIES. suffered ; and if the patient escape these, yet after a strong fit the functions ascribed to the nerves are every day more and more en- feebled, though without any fresh access of the distemper, lhe general health does not always suffer in proportion to the apparent violence of the attack. Some slight fits have been succeeded by a great and irremediable feebleness both of body and mind. After all fits, there is too apt to be left some degree of headache, giddiness, inattention, forgetfulness, sleepiness, slight delirium, inarticulation of the voice, hiccup, tremblings, weakness, cramps, and involuntary or causeless laughing and crying. Among the many ill consequences of apoplexies I have seen one good one, and that was in an epileptic person, who never had any return of the epilepsy after an apoplectic fit. But at other times it has happened, that an epilepsy first came on after a stroke of a hemiplegia ; and the same has been followed in a child by St. Vitus's dance. A long unsteadiness and trembling of the right hand entirely ceased, and the person, who had been a remarkable penman, was able to write again as finely as ever, upon being attacked with a palsy of the left side. I know no certain rule of judging how long a person may be strug- gling with an apoplexy or palsy, before he sinks under them, or be- gins to recover. A perfect apoplectic fit, in which no signs of life remain beside the motion of the heart and lungs, is seldom seen unless for a few hours before death. A less complete apoplexy, but yet without any sense, or voice, or power of swallowing nourishment, has continued for ten days before it proved fatal. A hemiplegia has been followed by death in a few months, in a few days, or in a few hours, and most commonly by an apoplectic fit supervening. But where a person has either been struck at first only with a hemiplegia, or has recovered into this state from an apoplexy, there most usually, instead of growing worse, the patient has been found to recover from some of the symptoms, and sometimes, though very rarely, from all of them. The signs of a beginning recovery have sometimes been perceivable in a few minutes, and sometimes have been delayed for several days, or even for some months, and the symptoms have been gradually retreating for several years. A man of eighty has recovered in two months. The use of the legs even in an old man has been regained after nine months, so that he was able to walk. In one hemiplegiac the motion of the parts began to return so late as the end of the second year. Two paralytic paroxysms in an old asth- matic man left no traces behind them, and he continued well for more than ten years. Many who have been almost in a senseless state with a hemiplegia, have been perpetually at work with their sound arm in shoving the bed-clothes from their breast. If the hemiple- giacs are desired to try if they can move the affected arm, they all of them presently take hold of it and move it about with the other hand. The most melancholy scene of this distemper is, when it has kept weakening all the powers of the body and mind by very slow degrees, and letting loose the passions almost to madness, so that a man sur- vives himself for several years, and is at last reduced to a most PARALYSIS ET APOPLEXIA. 14H miserable state (if he knew his own misery), in which he is unable to stand, to talk, to feed himself, or to retain his urine or stools, and yet lives on in this helpless condition for many months. Those who are near their end in an apoplexy, very remarkably puff out both their cheeks in every expiration. It is probable that far the greater part of paralytic and apoplectic patients would recover some degree of life and strength by the un- assisted efforts of nature. Hence arises a difficulty of ascertaining the real efficacy of any means which may have been used, unless often repeated trials should be found to have an uniform effect. Whenever any one falls down in an apoplectic fit, or is suddenly struck with a palsy, it is necessary in the first place to loosen whatever bandage may be about the neck ; for upon the access of these distempers I have known it instantly swell to such a size, that the person without this relief would be in danger of being strangled. Bleeding is one of the first means usually employed for the re- covery of an apoplectic person ; and if he be in the vigor of his age, or very plethoric, and accustomed to living in a full manner, it seems a very fit remedy, and likely to be highly beneficial. But an indis- criminate use of large and repeated bleedings in all apoplexies and palsies can hardly fail of being often attended with mischief, since the young and vigorous are not the most frequent victims of these maladies, but rather sickly children, and the old, the infirm, and ex- hausted, in whom the vis vitae wants to be excited, rather than lowered, and where bleeding will damp every effort of nature, and irrecovera- bly extinguish the small remains of life, as it is found to do in drowned persons. The practice of taking away blood must be founded either in experience, or theory ; and if I were to judge from the cases, which have occurred to me, I should say that the occasions, where it could be supposed to do good, have been extremely few, and that large bleedings have several times appeared to me to be prejudicial. Theory may teach, but will find some difficulty in proving, that apoplexies must arise from a compression of the brain, owing either to a distension of the blood-vessels, or to extravasated blood from their rupture, and that the energies of the nerves can be deadened by no other cause beside fulness. The usual subjects of palsies, as be- fore mentioned, do not favour this hypothesis; and the operation of several poisons in disturbing or annihilating the nervous functions can hardly be accounted for by such a theory: as little can it be re- conciled with the gradual manner in which most palsies, and many apoplexies, are found to advance, and with the strong disposition to relapses in those who have been emaciated and broken by many former fits. Some palsies must be owing to other causes besides ful- ness; and whatever these causes be, they may be the only ones of most palsies. A rupture of some blood-vessels in the brain may be the origin of some apoplexies, but probably of few ; because these can hardly escape being instantly fatal; and we know that there is a far greater proportion which do not end in present death. Some practical authors tell us they have been glad of finding a fever in a 150 HEBERDEN'S COMMENTARIES. paralytic ; or desirous of exciting one. This but ill accords with the evacuating, and cooling regimen. But I must own that I have no faith at all in this doctrine ; for, according to all my experience, the more fever there is, the worse it always fares with the patient, in every external and internal ail; and the more natural the pulse is, the more hopes there will be of a prosperous event. I have known the gout seize persons ill of paralytic complaints, without at all fulfilling the expectations of the patients and their friends by giving them the least relief; but this cannot appear strange to any one, who considers that the gout appears from experience to be rather a cause than the remedy of apoplectic diseases. No circumstances have encouraged me to hope for benefit from giving any other emetic than a little carduus tea, in order to make the person vomit more easily, and empty the stomach more effectually, where it was pointed out by the sickness and retching of the paralytic patient. A purge, if it can be given, or a sharp clyster, which may both unload and stimulate the bowels, is always useful; but violent purging has ap- peared to do harm, rather than good. Blisters should be applied as soon as possible to the head, between the shoulders, and to the paralytic limbs. The medicines proper to be given, when the patient is sufficiently recovered to be able to swallow, are such as have the general pro- perty of strengthening and invigorating ; which purpose is well an- swered by one drop of oil of cloves mixed with a little sugar, and then added to an ounce and a half of an infusion of Peruvian bark and bitters, which may be given every four hours. Musk, wild va- lerian root, and camphor, are also recommended as specifically friendly to the nerves, and possessed of virtues, which revive their languid motions, and soothe their irregular ones. The root of valerian has often been given without much apparent effect; but yet I have met with some, whom it threw into such agitations and hurries of spirits, as plainly showed that it is by no means powerless. Most cats are fond of gnawing it, and seem to be almost intoxicated by it into outrageous playfulness ; and the nerves of cats afford a very tender test of the powers which any substances possess of affecting the nerves. The poisoned darts of the Indians, tobacco, opium, brandy, and all the inebriating nervous poisons, are far more sensi- bly felt by this animal than by any other, that I know, of an equal size. When the patient is judged to be pretty well out of the reach of present danger, he must in the next place be assisted in freeing him- self from the several disagreeable relics of the former attack, and in preventing a return. For these purposes a journey to Bath is generally proposed: about which physicians seem to be divided in their opinions; some thinking, that the drinking and bathing at Bath help to recover paralytics, while others are persuaded that they are the ready means of turning a palsy into an apoplexy. If I were to judge from my own experience, I should say that the Bath waters do neither good nor harm to these patients; some of whom gradually PARALYSIS ET APOPLEXIA. 151 recover while they stay at Bath ; and others suffer a fresh attack and die there ; just as they would in any other place. I therefore cannot advise Bath ; but if it be desired by the invalids themselves, or any of their friends, there is no reason to hinder their going thither. There is not much more to be said in favour of the cold bath. Out of a great number of persons, whom I have known to use sea-bathing for several successive seasons, and long courses of cold bathing in weak- ness and giddiness left by palsies, some have thought them prejudicial, and more have thought them useful: but from all their accounts I have concluded, that cold bathing is innocent, or in a small degree benefi- cial. So that the chief reason against advising, or allowing it, is, that paralytics are liable to relapses of their disorder, let them do what they will; and if any fresh access, or aggravation of their symptoms should happen at the time of using the cold bath, or soon after, it would of course be charged, though very unjustly, to the bathing. Sleep is the great restorative after labour, and indispensably ne- cessary to life ; yet it unquestionably disposes the body to be in- vaded by all those diseases which are peculiarly attributed to the in- firm or disordered state of the nerves, and among them to apoplexies and palsies, many of which first appear, or are much aggravated during sleep. In all these maladies therefore it behoves those who wish to be restored from what they still suffer, and to prevent any further mischief, to be cautious of indulging themselves in sleep, and to be contented with as moderate a portion of it, as is found con- sistent with their general health. An issue should be made in the neck, as soon as the blisters are all healed, and should be kept open during life. The symptom of giddiness is moderated in those who can bear this small loss of blood, by taking away six ounces by cupping-glasses, more than by any other means: this has been well borne by those who could not bear the loss of blood from a vein by a lancet. I have known it expe- rienced in several, and particularly in a woman of sixty-eight, who had such bad fits of it, as made her several times fall, and frequently threatened an apoplexy. She began the cupping at that time of life, and used it constantly every six weeks until she died, which hap- pened at the age of eighty-five. She was in no danger of ever for- getting it; for she felt the most evident marks of wanting this relief, whenever she deferred it beyond the usual period. During all this time the giddiness was inconsiderable, and came but seldom. She was struck at last with a palsy, which had probably been kept off for many years by this practice of cupping. When I knew no more of physic than what I had learned from books, I was very apprehensive, as I was taught to be, and by plausible reasoning, that opium was hurtful in palsies and apoplexies; for it is supposed to have the effect of deadening the powers of the nerves, and therefore must be improper where we want to enliven them. This hypothesis, however specious, wants the attestation of experience. I have met with some, who, while they were recover- ing from a palsy, used opium plentifully, and afterwards never passed 152 HEBERDEN'S COMMENTAIi 1ES. a night without taking twenty or thirty drops of tinctura opii for many years: which practice did not hinder them from being very well, and was supposed to assist in making them so. In consequence of these examples, I have frequently given it in paralytic cases where the restlessness seemed to require it, and with as much advantage as in any other distempers.* The good success of electricity in paralytic maladies has not yet been sufficiently ascertained ; but it evidently has some influence over the nerves. An intermittent fever has more than once, during the fit, been attended with paralytic symptoms ; but these have all yielded, together with the fever, to the Peruvian bark. A Case of Catalepsy. 26th June, 1764, in St. Thomas's hospital, I saw a woman six-and- thirty years of age motionless with a fit of the catalepsy. Her pulse was quite natural: her breathing easy. Her eyes were fixed, as by attentive contemplation, not like those of a person who is either dying or sick, or under any pain or uneasiness. Her limbs all retained the situation in which they were placed by the by-standers, however in- convenient. I extended her arm, and saw it remain stretched out for twenty minutes ; and I was told it continued so on a former trial above an hour, which scarcely any body in health could support. I heard even that it would remain extended with a weight of seven pounds in the hand. If the patient was placed upright, she continued upright, and was not very easily thrown down. While she was sitting down both thelegswere extended, andraisedfrom the ground ; and they remained in that uneasy posture, as if they had been made of clay, or of wax. Her mouth was closed, and I was unable by any means to open it. The eyelids were constantly open ; or if forcibly closed, they opened again as soon as the force was removed. She winked, but in a very slight manner, upon moving the finger quick towards the eye; at other times the eyelids did not move. At the approach of a candle the pupil contracted. If the nostrils were compressed, after a little effort, and apparent struggle, the lips opened for the purpose of breath- ing. I heard that she had been in this state some months. The fits returned morning and evening almost every day, and continued some- times an hour, at other times three hours. The nurse reported that one fit had lasted twelve hours. She used to be suddenly seized, without any previous notice. CHAPTER LXX. Pectoris Dolor. Beside the asthma, hysteric oppressions, the acute darting pains in pleurisies, and the chronical ones in consumptions, the breast is often the seat of pains, which are distressing, sometimes even from * M. Chapelain, medecin de Montpellier, avoit gue>i un homme en apoplexie par un grain de laudanum.—Acad. Soy. des Scien. 1703, Hist. p. 57. PECTORIS DOLOR. 153 their vehemence, oftener from their duration, as they have continued to teaze the patient for six, for eight, for nine, and for fourteen years. There have been several examples of their returning periodically every night, or alternately with a headache. They have been called gouty, and rheumatic, and spasmodic. There has appeared no rea- son to judge that they proceed from any cause of much importance to health (being attended with no fever), or that they lead to any dan- gerous consequences ; and if the patient were not uneasy with what he feels, he needs never to be so on account of any thing which he has to fear. If these pains should return at night, and disturb the sleep, small doses of opium have been found serviceable, and may be used alone, or joined with an opening medicine, with a preparation of antimony, or with the fetid gums. Externally, a small perpetual blister ap- plied to the breast has been successful, and so has an issue made in the thigh. A large cumin plaster has been worn over the seat of the pain with advantage. The volatile, or saponaceous liniment, may be rubbed in over the part affected. Bathing in the sea, or in any cold water, may be used at the same time. But there is a disorder of the breast marked with strong and pecu- culiar symptoms, considerable for the kind of danger belonging to it, and not extremely rare, which deserves to be mentioned more at length. The seat of it, and sense of strangling, and anxiety with which it is attended, may make it not improperly be called angina pectoris. They who are afflicted with it are seized while they are walking, (more especially if it be up hill, and soon after eating) with a pain- ful and most disagreeable sensation in the breast, which seems as if it would extinguish life, if it were to increase or to continue ; but the moment they stand still, all this uneasiness vanishes. In all other respects, the patients are, at the beginning of this disorder, perfectly well, and in particular have no shortness of breath, from which it is totally different. The pain is sometimes situated in the upper part, sometimes in the middle, sometimes at the bottom of the os sterni, and often more inclined to the left than to the right side. It likewise very frequently extends from the breast to the middle of the left arm. The pulse is, at least sometimes, not dis- turbed by this pain, as I have had opportunities of observing by feel- ing the pulse during the paroxysm. Males are most liable to this disease, especially such as have past their fiftieth year. After it has continued a year or more, it will not cease so instan- taneously upon standing still; and it will come on not only when the persons are walking, but when they are lying down, especially if they lie on the left side, and oblige them to rise up out of their beds. In some inveterate cases it has been brought on by the motion of a horse or a carriage, and even by swallowing, coughing, going to stool, or speaking, or any disturbance of mind. Such is the most usual appearance of this disease; but some varieties may be met with. Some have been seized while thev 20 154 HEBERDEN'S COMMENTARIES. wece standing still, or sitting, also upon first waking out of sleep : and the pain sometimes reaches to the right arm, as well as to the left, and even down to the hands, but this is uncommon: in a very few instances the arm has at the same time been numbed and swelled. In one or two persons the pain has lasted some hours, or even days; but this has happened when the complaint has been ot long standing, and thoroughly rooted in the constitution: once only the very first attack continued the whole night. I have seen nearly a hundred people under this disorder, ot which number there have been three women, and one boy twelve years old. All the rest were men near, or past the fiftieth year of their age. Persons who have persevered in walking till the pain has returned four or five times, have then sometimes vomited. A man in the sixtieth year of his life began to feel, while he was walking, an uneasy sensation in his left arm. He never perceived it while he was travelling in a carriage. After it had continued ten years, it would come upon him two or three times a week at night, while he was in bed, and then he was obliged to sit up for an hour or two before it would abate so much as to suffer him to lie down. In all other respects he was very healthy, and had always been a remarkably strong man. The breast was never affected. This dis- order, its seat excepted, perfectly resembled the angina pectoris, gradually increasing in the same manner, and being both excited and relieved by all the same causes. He died suddenly without a groan at the age of seventy-five. The termination of the angina pectoris is remarkable. For if no accident intervene, but the disease go on to its height, the patients all suddenly fall down, and perish almost immediately. Of which indeed their frequent faintnesses, and sensations as if all the powers of life were failing, afford no obscure intimation. The angina pectoris, as far as I have been able to investigate, belongs to the class of spasmodic, not of inflammatory complaints. For, In the 1st place, the access and the recess of the fit is sudden. 2dly, There are long intervals of perfect health. 3dly, Wine, and spirituous liquors, and opium, afford considerable relief. 4thly, It is increased by disturbance of the mind. 5thly, It continues many years without any other injury to the health. 6thly, In the beginning it is not brought on by riding on horse- back, or in a carriage, as is usual in diseases arising from scirrhus, or inflammation. 7thly, During the fit the pulse is not quickened. Lastly, Its attacks are often after the first sleep, which is a cir- cumstance common to many spasmodic disorders. Yet it is not to be denied that I have met with one or two patients, who have told me they now and then spit up matter and blood, and that it seemed to them to come from the seat of the disease.' In PEDICULARIS MORBUS. 155 another, who fell down dead without any notice, there immediately arose such an offensive smell, as made all who were present judged that some foul abscess had just then broken. On opening the body of one, who died suddenly of this disease, a very skilful anatomist could discover no fault in the heart, in the valves, in the arteries, or neighbouring veins, excepting some small rudiments of ossification in the aorta. The brain was likewise every where sound. In this person, as it has happened to others who have died by the same disease, the blood continued fluid two or three days after death, not dividing itself into crassamentum and serum, but thick, like cream. Hence when a vein has been opened a little before death, or perhaps soon after, the blood has continued to ooze out as long as the body remained unburied. With respect to the treatment of this complaint, I have little or no- thing to advance : nor indeed is it, to be expected we should have made much progress in the cure of a disease, which has hitherto hard- ly had a place or a name in medical books.* Quiet, and warmth, and spirituous liquors, help to restore patients who are nearly exhaust- ed, and to dispel the effects of a fit when it does not soon go off. Opium taken at bed-time will prevent the attacks at night. I knew one who set himself a task of sawing wood for half an hour every day, and was nearly cured. In one also the disorder ceased of itself. Bleeding, vomiting, and purging, appear to me to be improper. CHAPTER LXXI. Pedicularis Morbus. 1762. Aug. 23. I was this day informed by Sir Edward Wilmot, that he had seen a man who was afflicted with the morbus pedicu- laris. Small tumours were dispersed over the skin, in which there was a very perceptible motion, and a violent itching. Upon being opened with a needle they were found to contain insects in every re- spect resembling common lice, excepting that they were whiter. Sir Edward Wilmot ordered a wash, consisting of four ounces of spirits of wine, four ounces of rectified oil of turpentine, and six drams of camphor. The day following he told me all the insects had been killed on being touched with this liquor, and that all the itching had immediately ceased. * Ccelius Aurclianus, as far as I know, is the only ancient writer who has noticed this complaint, and he but slightly: " Erasistratus memorat paralyseos genus, et para- doxal appellat, quo ambulantes repente sistuntur, ut ambulare non possint, et turn rursutn ambulare sinuntur." Chron. lib. ii. c. 1.—M Saussure in his Voyage dans let Alpes says, that at the height of 13 or 1400 toises above the sea, a peculiar tiredness often comes upon thoso who are ascending such high hills, so that it is impossible to proceed four steps further; and if it were attempted, such strong universal palpitations would come on, as could not fail to end in swooning. Upon resting three minutes, even with- out sitting down, this tiredness passes, and the power of going on is perfectly restored. The climbing of steep hills, which are not so high above the sea, does not occasion this peculiar fatigue. Vol. i., p. AS'i. 156 IIEBE RDEN S CO MM EN T A RI ES. CHAPTER LXXII. Phthisis Pulmonum. A consumption appears by the London bills of mortality to be in that city the most destructive of all maladies to adults; one in four of those that grow up to manhood being reported to be carried off by this distemper. But all these must not be charged to the account of a pulmonary consumption ; because whoever decline and waste away by any obscure, unnamed distemper, are all charged to this article, though the lungs be not at all diseased. The phthisis pulmonum usually begins with a dry cough, so slight and inconsiderable, that little or no notice is taken of it, till its con- tinuance, and gradual increase, begin to make it regarded. Such a cough has lasted for a few years without bringing on other complaints. It has sometimes wholly ceased, and after a truce of a very uncertain length it has returned, and after frequent recoveries and relapses, the patient begins at last to find an accession of other symptoms, which in bad cases will very soon follow the appearance of the first cough. These are, shortness of breath, hoarseness, loss of appetite, wasting of the flesh and strength, pains in the breast, profuse sweats during sleep, spitting of blood and matter, shiverings succeeded by hot fits, with flushings of the face, and burning of the hands and feet, and a pulse constantly above ninety, a swelling of the legs, and an obstruction of the menstrua in women ; a very small stone has sometimes been coughed up, and in the last stages of this illness a diarrhoea helps to waste the little remainder of flesh and strength. A spitting of blood has sometimes been the first symptom ; but while it is found alone, it is but a slender proof of an imminent consump- tion, even when the blood certainly flows from the lungs ; and many have been unnecessarily alarmed by the appearance of what came only from their nostrils, gums, or throat.* But this, when united with other symptoms, is of great importance in determining the true seat of the distemper. The spitting of matter would at least be as certain a proof, if we had any infallible signs by which to distinguish the matter of an ulcer from the mere exudation of an inflamed mem- brane ; but all the criteria mentioned in books are insufficient for this purpose ; and I have known some attentive and very experienced physicians mistaken in their judgment upon this point. All the other symptoms of a pulmonary consumption, except bloody and purulent spitting, I have observed in one, whose mesenteric glands after death were found to be scirrhous, but whose lungs were sound. However, this happens so very seldom, that very little doubt is to be made of the diseased state of the lungs, where all the other symptoms concur, though these two should be wanting. A shortness of breath, and a quick pulse, are the two most dangerous signs in a suspected phthisis. I have known a person die of a con- sumption, whose lungs upon dissection'were found in a most diseased * s:(.c cliaptrr Ixxxiv., on spitting of blood. PHTHISIS PULMONUM. 157* state, and yet during the whole illness there was no spitting of blood, no pain of the breast, nor any difficulty in lying upon either side. A consumption is a distemper of that kind, which is most certainly derived from the parents, and yet rarely makes its appearance before puberty; between which and the age of thirty is the time of the greatest danger. Some have been attacked at forty, and have died after struggling with it four or five years. Others have been afflicted with a cough every winter for twenty years, or more, who so late in life as at the age of fifty have had all the other phthisical symptoms come on very hastily, and have died truly consumptive. The more com- mon event of such a long cough has been to degenerate in the decline of life into an asthma. Some violent causes, such as the measles, hooping-cough, or peripneumony, may make the latent seeds of a pulmonary consumption begin to appear, or may form this distemper, even in childhood, or decrepit age, of which there have been too many examples. The persons most subject to a pulmonary phthisis are those who are born of consumptive parents, and those in whom, during their infancy, or childhood, the mesenteric glands, or the lymphatic glands of the neck and jaw were swelled, and scirrhous, and especially if they have suppurated. We are too little acquainted with the animal economy to account for this disposition of these glands to swell in the earliest part of life, and that of those in the lungs to be affected in youth and manhood ; while it is more usually after the meridian of life, that the glands in the breast of women and in the womb begin to be diseased, and likewise the prostate gland in men, and those of the stomach, intestines, and other abdominal viscera in both sexes. In women of consumptive habits the state of pregnancy seems to hasten the appearance of the cough, and of all the other symptoms : the distemper makes a rapid progress at this time, and yet the patients often hold out beyond expectation till they are brought to bed, and not long after. The state of the pulse is of great importance in acquainting us with the degree of danger in a cough, which, on account of its duration, and of the bad symptoms with which it is accompanied, begins to be of a suspicious nature. A young man of eighteen, together with a cough, had a spitting of blood, a shortness of breath, vomiting, pains in the side, night sweats, and was much wasted for two years ; but with these complaints his pulse was hardly quicker than it should be, and in three years he had perfectly recovered his health. Nor is this the only instance of the kind, of which I have been a witness, I impute the cure not to any medicine, but rather to the patient's constitution, which was neither scrofulous, nor derived from con- sumptive parents ; and therefore the hurt done to his lungs by a vio- lent cold, which he had catched, might be considered in the same lio-ht with a wound made in the lungs of a healthy man ; which, though it be attended with many consumptive symptoms, yet we know by experience may be healed, and the health restored. Some- thing of the same kind is observable in peripneumonies, from which, • 153 HEBERDEN'S COMMENTARIES. after great inflammation, and cough, and spitting of blood, many have perfectly recovered. In England we have very little apprehension of the contagious nature of consumptions ; of which in other countries they are fully persuaded. 1 have not seen proof enough to say that the breath of a consumptive person is infectious; and yet I have seen too much appearance of it, to be sure that it is not; for I have observed several die of consumptions, in whom infection seemed to be the most pro- bable origin of their illness, from their having been the constant com- panions, or bed-fellows, of consumptive persons. Our great experience of this distemper has hitherto availed but little in enabling us to find out an effectual remedy. The cure of a disease inherited from parents, or owing to such a vitiated habit of body, as that, which is called scrofulous, has proved at least as diffi- cult as it might have been expected, and physicians have hardly ad- vanced further towards it, than by being able to mitigate some of the symptoms. Asses milk puts some check upon the tendency to ema- ciate. The dilute acid of vitriol in a decoction of bark is a very effectual remedy of the night sweats, and, as far as I have seen, is perfectly safe in all stages of this malady. A shortness of breath is no reason against using either this medicine, or an opiate at bed-time, which is the most certain soother of the cough, and saves the patient from being harassed with a restless night after a wearisome day. Where the pain of the side is violent, it will require, and is gene- rally relieved by taking away four or five ounces of blood. If this pain be rather lingering and teazing, than violent, a small blister applied to the part rarely fails of making a cure. A diarrhoea has seldom resisted three or four drops of tinctura opii taken after every stool. No medicines need be directed for the hoarseness, swelling of the legs, or obstruction of the menstrua, which necessarily belong to the disease of the lungs and windpipe, and to the weak, exhausted state of the patient, and are no otherwise to be cured, than by curing the principal distemper. The fever and the signs of inflammation may rise so high, as to justify the losing a little blood; but frequent bleedings, though small, have appeared to injure the patient, by con- spiring with the distemper to rob him of his flesh and strength. Dissections of those who have died of pulmonary consumptions, have acquainted me, that their lungs are full of little glandular swel- lings, many of which are in a state of suppuration. They appear to be of the same nature as the strumous swellings in the neck, but must always be more dangerous, because the texture of the lungs disposes them to spread, and because the office of the lungs is necessary to life, so that they cannot be greatly injured without the worst effects upon the health. , Many medicines have been delivered down from former physi- cians, as remedies in strumous diseases; the efficacy of all which have upon trial appeared so dubious, that I cannot from experience recommend any of them as likely to correct the strumous habit, or to disperse the glandular swellings of the lungs which have not yet PHTHISIS PULMONUM. 159 suppurated, or to heal those which are already ulcered, or to prevent any more from becoming scirrhous.' In this case therefore, as in all others where the proper remedies have not yet been discovered, the patient must be contented with instructions, which may enable him to avoid what has been found to aggravate the distemper, and by a proper regimen to put the general health into the best possible state ; that the natural powers implanted in the body of readjusting any dis- ordered part, may be able to exert themselves with the greatest vigor : nor needs the patient to despair of success from this care and attention. The breasts of women seem to be as full of glands, and of as lax a texture as the lungs ; yet I have sometimes seen scirrhous knots in them of a very alarming appearance, which have dispersed, or be- come indolent, so that a final stop was put to any further mischief, merely by a proper diet and the strength of their constitution. That something of this kind may happen in regard to the lungs is probable ; for some, who in their youth have had symptoms of a con- sumption in great number, and in no inconsiderable degree, have recovered and reached old age without any relapse. This was the case with that very ingenious and learned physician Sir Edward Wilmot, who, as he told me, when he was a youth, was so far gone in a consumption, that the celebrated Dr. Radcliffe, whom he con- sulted, gave his friends no hope of his recovery : yet he lived to be above ninety years old. A youth of sixteen, after having the usual signs of a phthisis for many months, and being apparently in the last stage of it, was almost suffocated by bringing up at once a great quantity of matter, and, after a few days, the bag, in which it had probably been contained. He soon recovered his flesh and strength, became a strong man, and lived to old age, with a family of robust children and grandchildren; yet he was remarkably subject to a cough upon every slight cold, and had returns of spitting of blood several times every year. It is common to have very bad consumptive symptoms abate, and keep quiet for a whole summer, or for a few years, and then after some severe weather, or intemperance, or catching cold, to return, and end fatally. Now, whatever has checked the distemper for a year or two, might possibly have kept it under till old age. Agree- ably to this supposition, I have known an hereditary consumption at the age of twenty-nine cured after removal into a warm climate, without any relapse for twenty years ; and I know not that it ever returned. An ample provision has been kindly made, sometimes by- duplicates, of several parts of the body which are indispensably useful to life, that in case one of them, or some part should fail, there may still be enough remaining to answer their purpose in a tolerable manner. The lungs afford an example of this ; for in bodies, which have been opened, one lobe has sometimes been almost annihilated, and so much of the other destroyed, as to make it probable, that not only life, but even tolerable health might be carried on after the strumous swellings had made great ravages in the lungs, if we had but the means of stopping the mischief here, and of effectually hinder- 160 HEBERDEN'S COMMENTARIES. ing it from going any further. This is confirmed by what is seen in pocky consumptions, from which, by means of the specific antidote, many have been restored to health after great injury done to the lungs. Hereafter we hope there may be found out as certain a remedy for the strumous virus. In the meantime the consumptive patient does not want encouragement to persevere steadily in a strict regimen, and a solicitous shunning of whatever may weaken the natural strength, or aggravate the distemper. Cold weather, and bleak winds, will occasion coughs in the sound- est lungs, and cannot be too carefully avoided, where they are mor- bidly tender. Warm covering, as a flannel waistcoat, will have its use; but where a removal to a warm climate is not impracticable, this will prove the most successful means. An island without any very high hills on it, and at a sufficient distance from the snowy mountains of the continent, and where the heat is from sixty to ninety degrees, is the most favourable situation; for it enjoys an equal temperature, secure from bleak winds. In the three or four summer months, the air of England is as mild as the tenderest lungs need breathe, and there can be no use in leaving this country from May until October; but for his abode during the other months, the consumptive patient should remove to such a situation as has been mentioned. The exercise which( he can take with the most pleasure, and with the least fatigue, will be* the most desirable. In his diet he must abstain from all wine and spirituous liquors, and either wholly, or as much as he well can, from meat. There are some, who arevery averse from vegetables, and all farinaceous food, and to such a moderate indulgence of their taste must be allowed, lest a total abstinence should weaken the patients more than the distemper : the cravings of the appetite, though not entirely to be gratified, yet are not in any illness to be wholly disregarded. The water which is used should be the purest that can be had, such as springs out of the Melvern hills, or distilled water. Those waters which are loaded with lime-stone and mineral acids, will be ex- tremely pernicious. I have great reason to believe, that such im- pure waters have a strong tendency to obstruct the lymphatic glands, and make them become scirrhous and ulcered, even in adults, who have no hereditary strumous taint; and I think I have evidently seen such dispersed by the use of purer waters. Sailing, so as to be out at sea'for some months, has been tried by some for whom I have been consulted, and they have thought it useful. However, it has failed in others ; and I can go no further in its commendation, than to say, that consumptive patients have borne it well, even those whose principal symptom was a spitting of a great quantity of blood ; which complaint has not been in the least aggravated by a voyage of six weeks, notwithstanding the sea-sick- ness was so great, as to make the patient vomit excessively during the whole time. A disagreeable tickling in the throat, causing a constant provo- cation to cough, is sometimes so importunate as to force the patient PICTONUM C0LICA. 161 to have recourse to various means of procuring some present re- lief: a few raisins will sometimes answer this purpose ; for which innumerable other sweet and soft things have been employed, as a little liquorice-root tea, rob of elder, currant jelly, jelly of quince- seeds sweetened with some syrup, a mixture of oil, honey, and lemon-juice, to which, or similar compositions, it is sometimes re- quisite to add a small portion of syrup of white poppies. A lump of sugar moistened with a few drops of tinctura opii camphorata has been very serviceable. Of all which it must be remembered, that they can only afford a little temporary ease, that they do not con- tribute in the least to the cure of the distemper, that they pall the appetite, and therefore should be used very sparingly. CHAPTER LXXIII. Pictonum Colica. There appear two species of this disorder, one of which may be called the acute, and the other the chronical. In the former, the pain of the stomach and bowels comes on suddenly, and is exces- sively great, joined with an obstinate costiveness, and sometimes with a stupor and loss of understanding, and ends in a palsy of the hands, if not in death. The chronical begins with dull pains of the bowels, not always accompanied with costiveness, which sometimes increase so as to be very tormenting, sometimes are inconsiderable, or cease ; they continue in this way for half a year, for two, for three, for five, or ten years, before the hands become paralytic : at which time in both these colics there rises in several, but not in all, a swelling on the back of one or of both hands, about the begin- ning of the metacarpal bone of the middle finger, of the size of a small nut, without pain or change of colour. After the more violent colicky pains have ceased, and the palsy has come on, a dull pain of the stomach has remained, accompanied with flying pains all over the body, with very little appetite, if not with sickness and vomit- ing. The patients have continued gradually to lose their flesh (par- ticularly in the ball of their thumb) and their strength, and not long before death have grown delirious and blind. The legs have been paralytic for a night, and I have remarked some, but not many cases, in which they too as well as the hands have been affected with a lasting palsy. Anxiety, restlessness, and want of sleep, harass these patients almost as much as the pain ; they are perpetually turning themselves in bed, and when they are able to keep out of it, they are walking to and fro all day. Muscular pains all over the body (more particu- larly the scapuhe), extreme languor, hiccups, want of appetite, vomit- ing and a drawing in of the navel, are not unusual attendants upon a tit. A quiet sort of delirious talkativeness, without any fever, will continue in some for a little while after the fit has ceased. In a chro- nical Saturnine colic the fits have kept returning every two or three 21 162 HEBERDEN'S COMMENTARIES. months for several years, lasting from one week to a month or lon- ger. In time, as the distemper becomes stronger, and the body weaker, the fits return more frequently; and even in the intervals the patients are far from being perfectly well. The pulse is less quick- ened in the fit, than might be expected from such exquisite anguish. When the difficulty of procuring stools is conquered, the patient finds some relief from them, and often not much. A person has been ap- parently dying in a fit of this colic, and in two days has been well enough to go abroad. Some of these patients have expired suddenly; and such an event may probably have been owing to the peculiar mischief which the nerves suffer from the poison of lead. Upon opening the abdomen of one, who died of this colic, nothing preternatural could be discovered. All the solutions and calxes of lead will certainly occasion this disease. The acute colic perhaps arises from a large quantity of this poison taken in a short time ; and the chronical from very small quantities persisted in for a long time. Experience had taught man- kind these singular effects of lead near two thousand years ago; and it has not yet been clearly and satisfactorily discovered that they have ever been produced by any other causes, though some have been suspected. It is remarkable, that the chronical Saturnine colic has often attacked only one person in a large family, all of which, as far as could be learned, lived in the same manner. But this must not be urged as an argument, that it could not be produced by lead; because it would prove equally against any other external cause. The very small quantity of this poisonous metal, which is sufficient to produce the peculiar symptoms, makes it extremely difficult to trace its passage into the stomach. Three grains of sugar of lead, taken every day for four days, brought on colic, costiveness, inquie- tude, and loss of appetite. Thirty drops of the Saturnine tincture taken every day for a month created a colica Pictonum, which was long troublesome, though cured at last. It is hard to estimate the precise quantity of lead in these thirty drops, but I judge it can hardly exceed a grain. In the tinning of copper vessels much lead has ge- nerally been mixed with the tin, and if one of the family were to use a greater quantity of what had been boiled in such vessels, espe- cially if he were fond of acid sauces prepared in them, this would afford the ready means of accounting for that person's being singled out as the only sufferer. Dried acid fruits, or their jellies or rob, or pickles made in tinned or glazed vessels, or vinegar if it were kept any time in such, might easily be made the vehicles by which the lead was conveyed into the stomach; and the liking which some have for these, and the indifference, or aversion of others, may ac- count for the unequal portions of lead, which may fall to the share of different persons in the same family. This poison might also lurk in some of the liquors used in the same house, and not in others ; and besides, like all other nervous' poisons, may have stronger effects upon peculiar constitutions. Three or four persons, who drank only white Lisbon wine from half a pint to a pint daily, have complained PITUITA. 163 of this colic, and a consequent palsy, of which I suspected the wine was the cause; and the good effects in one of them upon leaving it off confirmed my suspicion. The acute species of this distemper has never occurred to me, un- less among plumbers, or painters, or those who had been exposed to the fumes of melted lead, the dust of old lead, or its calxes. The unknown manner in which the lead is introduced into the stomach in the chronical colic makes probably the great, and often unconquerable difficulty of curing it. For if, from not being aware how they take this poison, they continue to take it on, no remedies can be of any avail; and accordingly most of these cases have proved incurable. Many children probably die of this distemper (though confounded with their other bowel complaints), which they contract by having playthings painted with white or red lead, and by putting them, as they are apt to do, into their mouths. The painters of these playthings are liable to this illness ; and I have had them under cure for it. The first attack even of the acute species of this colic has not always ended in a palsy; and by quitting the employment which occasioned it, the cure of a very bad fit has not been succeeded by a relapse. Some active purge to procure a passage, and opium, if it be necessary, to allay the pain, and soothe the convulsions of the bowels, or a warm bath, and sometimes a blister to the belly, have proved the most successful remedies in a violent fit of the colica Pic- tonum. Aromatic and bitter infusions seems to be pointed out after the fit is over, as the properest means to recover the stomach and in- testines from all the ill effects of the Saturnine poison, and to prevent or to cure the paralytic weakness, which so generally succeeds to re- peated fits. Bath water, from its friendly effects upon debilitated stomachs, promises to be useful in this disease; and though some have found no benefit, yet others have been much restored at Bath, and perhaps the sooner for having used those waters both inwardly and outwardly. There is a further use in a Bath journey to those who are afflicted with the chronical colic; for by changing their manner of life, and their liquors, and culinary vessels, they may hope to cut off the communication which the lead had found to their sto- machs, and against which, by being unknown, they were at a loss how to guard themselves at their own homes. CHAPTER LXXIV. Pituita. An inundation of phlegm, almost to a degree of choking, espe- cially in a morning, is to many a very afflicting complaint, and is chiefly heard of among those whose strength has begun to decline, either by the approach of age, or by the shock of some distemper. This phlegm has been much lessened by a vomit, to the great relief of the patient ; afterwards, to keep it under, it has been found advisable to take every day half a scruple of columbo root with one 164 HEBERDEN'S COMMENTARIES. grain of long pepper, in powder or in pills ; to which may be occa- sionally added a grain of aloes, if there be any tendency to costive- ness, which would much aggravate this complaint. CHAPTER LXXV. Prostata Scirrhus. A scirrhus of the prostate gland has been observed only in adults, and chiefly those who were in the decline of life. The symptoms are, some degree of tenesmus, a pain in expelling hard feces, and a frequent irritation to make water, which comes away with pain, stretching sometimes to the extremity of the urethra, and passing up to the kidney. In the advanced state of this malady, a bloody mucus follows the urine, and the testicles swell. The ulcer has sometimes penetrated into the rectum, and wind has passed through the ulcer into the urethra, and come out with the urine. There is a great resemblance between these symptoms and those of a stone in the bladder; and the two distempers are not always readily distinguishable. The two principal criteria are, that in a diseased prostate the pain precedes, and in the stone it follows the making of water; then, riding in a carriage, or on horseback, which so much increases the bloody water and anguish of a calculous pa- tient, is borne in a scirrhus of the prostate, even in its ulcered state, without any aggravation of the pain, or any more copious discharge of bloody mucus. Wherever this disorder is suspected, the assist- ance of a surgeon should be desired, who by an examination will seldom fail to discover the swelling, if it be considerable; but in the early state of this disorder I have known surgeons, after they have examined, differ in their opinions about the state of this gland.* A scirrhous prostate hardly admits of a cure. Mercurials have appeared to do mischief. A decoction of the Peruvian bark, with as much extract or powder of hemlock as can be borne without gid- diness, is at least safe. An opiate clyster made of five or six ounces of water either warm or cold, and from thirty to a hundred or more drops of tinctura opii, cannot be enough commended for the impor- tant services which it is capable of doing these patients." One of them taken constantly at bed-time will always insure a tolerable night; and it may be repeated in the day, whenever the pain is excessive, with a certain effect of procuring ease. Besides these, I know no other useful instructions, which these patients can have from a phy- sician; for their own prudence will teach them, that regular hours, temperance, and a strict abstinence from all heating food and liquors, must be rigorously observed. CHAPTER LXXVI. Pruritus Cutis. The scrotum of men, and the pudenda of women, are subject to ♦See above, chapter xvi,, on the stone. puerperium — purpurea: macll.e. 165 be afflicted in a very tormenting manner with itching, which has continued for many years. In women this complaint is often joined with the fluor albus, and may be partly owing to the irritation of this acrimonious humour drying upon their skin for want of being duly washed off. There is besides, an universal itching of the skin, without any eruption, or jaundice, familiar to very old men, and to those whose health is much broken with gout or palsy, harassing them both day and night, and hardly suffering them to get any sleep. Elderly men often experience likewise a slighter itching about the scapulas. Warm bathing has been tried with very little success. A wash of spirit of wine has allayed the itching for an hour. An infusion of white hellebore root, as directed under cutis vitia, has in some cases made an effectual cure. A very beneficial lotion has also been pre- pared from a solution of alum, from sea-water, tar-water, and a de- coction of staves-acre. In some constitutions it has been judged useful to open an issue in the thigh. I know no use of any internal medicines. CHAPTER LXXVIL Puerperium. Beside great marks of weakness, and of a shattered constitution, left by difficult labours and puerperal fevers ; and beside some dis- eases, as mentioned under their proper heads; a thick miliary eruption has covered every part of the skin in a lying-in woman, without any one bad symptom, and has lasted three days. Was this entirely owing to keeping her too hot? It has also been observed, that sometimes a little before, or a few days after the end of the first month, one of the thighs has begun to be painful, not without fever, and has swelled to an enormous size, with great hardness, and ina- bility to extend the leg. This swelling has continued near a month, before the thigrl has been reduced to its natural size, and before the use of it has been fully restored. The paralytic, and maniacal complaints, to which the puerperal state is subject, have been sooner, and more perfectly cured, than when they have been brought on by any other causes. The puer- peral fever must be treated like other similar fevers. Bleeding is proper in the beginning. CHAPTER LXXVIII. Purpurea Maculae. Some children, without any alteration of their health at the time, or before, or after, have had purple spots come out all over them, exactly the same as are seen in purple fevers. In some places they were no broader than a millet-seed, in others they were as broad as 166 HEBERDEN'S COMMENTARIES. the palm of the hand. In a few days they disappeared without the help of any medicines. It was remarkable, that in one of these, the slightest pressure was sufficient to extravasate the blood, and make the part appear as it usually does from a bruise. A boy four years old, for several days had swellings rise on his knees, legs, thighs, buttocks, or scrotum. The part affected was not discoloured, and when at rest, was easy, but could not be moved without some degree of pain. Together with these swellings Ihere appeared red spots, sometimes round, sometimes angular, a quarter or half an inch broad, which on the second day became pur- ple, and afterwards yellow, just as it happens from a bruise. The child continued perfectly well in all other respects. These swell- ings ceased to appear in about ten days; but the red spots con- tinued coming out a few days longer. Another boy five years old, was seized with pains and swellings in various parts, and the penis in particular was so distended, though not discoloured, that he could hardly make water. He had sometimes pains in his belly, with vomiting, and at that time some streaks of blood were perceived in his stools, and the urine was tinged with blood. When the pain attacked his leg, he was unable to walk ; and presently the skin of his leg was all over full of bloody points. After a truce of three or four days the swellings returned, and the bloody dots, as before. These dots became paler on the second day, and almost vanished on the third. The child strug- gled' with this uncommon disorder for a considerable time, before he was entirely freed from it. The first of these boys immediately grew better after being gently purged: the other took a decoction of the bark for several days without any manifest good effect. CHAPTER LXXIX. Rheumatismus. The rheumatism is a common name for many aches and pains, which have yet got no peculiar appellation, though owing to very different causes. It is besides often hard to be distinguished from some, which have a certain name and class assigned them : it being in many instances doubtful, whether the pains be gouty, or vene- real, or strumous, and tending to an ulcer of the part affected. There are two different appearances of the rheumatism, one of which may be called the acute, and the other the chronical. The acute species is attended with great restlessness, and intole- rable pain upon moving the affected joint, which likewise swells and acquires a faint blush of redness. The degree of fever as far as is denoted by the quickness of the pulse, less injures the faculties both of body and mind, in the rheumatism, than in any other dis- temper ; for what might be considerable enough to make others de- lirious, will scarcely make these patients lose their appetites or RIIEUMATISMUS. 167 show much sign of distress, or of sinking under their illness. The pains and swellings, contrary to what happens in the gout, have in the first fit seized successively many different parts, seldom remain- ing long in any, and have continued in this manner sometimes for more than two months. These patients are subject to excessive sweats without any relief. Many of them have their pains greatly increased by the warmth of a bed: but this is not constant; for some, especially in the chronical species, are easier in bed. The rheumatism has in more than one or two patients returned once or twice a year for several years, and upon account of this cir- cumstance it is a borderer upon the gout, and many would doubt to which of the two distempers it properly belonged ; for though one, who has had a fit of a rheumatism, may have a second or third, yet it has seldom been found to be regularly periodical in its returns; oftener indeed it has never returned at all. The rheumatism is un- doubtedly nearly allied to the gout; and fits of it have been more common in children born of gouty parents; as if it were a prelude to what they were afterwards to suffer. The chronical species equally partakes of the palsy; for there is always a trembling, weak- ness, and numbness left for some time in the limb affected, and in the chronical sort the use has at last in many been wholly taken away. A rheumatic pain in the shoulder of a woman gradually weakened the arm, till it became almost paralytic and useless: in six or seven months the motion of the arm began to return, and after the use of Buxton water, was perfectly restored. Strumous constitutions like- wise have appeared particularly liable to pains, and swellings, either rheumatic, or by every mark exactly resembling them. Such have either forerun, or accompanied strumous ulcers, and collections of matter; and strumous ophthalmies have more than once been changed into rheumatic pains of the limbs. A pain with a swelling fixed in a single part, as the knee, or wrist, without ever removing to any other, is hardly to be called rheumatic, and is more likely to be a cramp, or strain, or strumous, that is, to have a tendency to an ulcer from some internal cause. An exception however must be made in regard to the sciatica, which is of the rheumatic kind, though it be fixed in the same part: as for the lumbago, it seems to be rather a cramp, or strain. The chronical differs from the acute rheumatism in being joined with little or no fever, in having a duller pain, and commonly no redness, but the swellings are more permanent, and the disease of much longer duration ; for if the acute species have continued some months, the other has continued for many years. It oftener happens that the fits return, at no certain intervals, till they have brought on a deplorable weakness, or entirely destroyed the health. Both kinds of the rheumatism attack indiscriminately males and females, rich and poor. The rheumatism has appeared so early as in a child only four years old, and I have seen several afflicted with it at the age of nine years : in which it differs from the gout, which I never have observed before the years of puberty. 168 HEBERDEN'S COMMENTARIES. Many of the worst rheumatisms have never offered to go beyond the external muscle and joints ; yet I have seen some, in whom the rheumatism has spontaneously passed these bounds, and attacked the stomach, or head. As in a great number of rheumatisms this has happened so seldom, it maybe, that those disorders, in which the sto- mach and head have been affected, were more truly gouty or strumous, or belonged to the chronical rather than acute rheumatism. An immo- derate vomiting, and restlessness, and entire loathing of every thing, which ended in death, occurred in the case of one man, whose com- plaints in many respects partook more of the nature of rheumatism, than of gout. The rheumatism is not more like the gout in its appearance, than in the little progress which has hitherto been made in settling the pro- per method of cure ; which perhaps is partly owing to the different disorders, which have been called by this name. In the acute sort, bleeding has been much trusted to, which is so much dreaded in that very similar distemper the gout: and it seems to be plainly pointed out in young persons of vigorous health, who have contracted this ill- ness by the common causes of inflammatory distempers, such as be- ing exposed to cold air when they were heated with labour. But as much as I have been able to observe, the benefit of large and repeated bleedings is in most cases far from being clear and unquestionable. One of the worst rheumatisms, which I remember, immediately suc- ceeded a most profuse bleeding of the nose, which continued so long as almost to exhaust the patient, and to bring his life into imminent danger. Something like this has happened in a second instance. Among the common people, tradition has preserved the use of the linum catharticum, and other very strong purges; but these have not been attended with such good effects, as to establish their general usage. Sweating is another evacuation, which has been employed both in the acute and chronical rheumatism, and sometimes, as it has seemed, with advantage ; but it is notorious, that these patients are of themselves subject to excessive sweats without any mitigation of the distemper. I have remarked some instances, in which warm bathing seemed prejudicial, but not one, in which it did any good in either species of this distemper. Cold bathing has often been useless, but at least as often serviceable. A blister has relieved the more fixed pains of the cronical rheumatism ; and the volatile and saponaceous liniments have been rubbed in upon the parts affected, and perhaps with benefit. The motion of a carriage has been so far from increasing these pains, even when they have been very bad, that some patients have been easier when travelling, than when sitting still in their chairs. Preparations of quicksilver have been frequently given with purg- ing medicines, and sometimes with an opiate ; but there will be cause of hesitating about making use of mercurial preparations, since they have indubitably in many cases constantly brought on fits of the rheumatism : and never could be used, though several times tried, without having this effect. The rheumatism has in some persons SEMEN VIRILE— SINGULTUS. 169 been the sure attendant upon a venereal disorder, probably in con- sequence of the mercury which had been used for its cure. The Peruvian bark, gum guaiacum, the Portland powder, prepara- tions of antimony, a mixture of nitre and volatile salt, the powder or infusion of bogbean and other bitters, are supposed to possess some specific virtue in the cure of this malady; but all these must be looked upon as being in a state of probation only, not as being yet established in the class of efficacious remedies. Opium, notwith- standing Sydenham's objections, has at least proved a safe and effec- tual remedy for the purpose of mitigating the pains, and of procu- ring easy nights of sleep; and has not only palliated the symptoms, but has been judged to contribute to the cure of the rheumatism, more by its calming, than by its sudorific power: nor do I know that it is more efficacious, when administered in Dover's powder, or mixed with antimony, than when given alone. Pains of the hips are well known to arise sometimes from a mor- bid state of the joint, of a very different nature from the rheuma- tism.* CHAPTER LXXX. Semen Virile. Intemperance in venereal pleasures is punished with various symptoms of weakness, generally causing a greater languor of mind, than of body, proceeding from the reflection upon that misconduct, which has done this injury to the health. In these cases the semen will come away too promptly both in sleep, and in the day-time, and sometimes without the person's having any sense of it. Cold bathing has been useful in such complaints; but living in a more cautious manner, and abstaining from all the practices, which occasioned them, is the most effectual remedy, and what I believe will seldom fail. I have in two persons known the semen of a chocolate colour, probably owing to the breach of some small blood-vessel. This dis- colouring has continued for some time, but without any bad conse- quences. CHAPTER LXXXI. Singultus. A hiccup is the companion both of chronical and acute distempers. It has been the forerunner of epilepsies, and has attended palsies, and seldom fails to be one of the symptoms of diseased livers, and sometimes will belong to simple obstructions of the gall-ducts. \ a- rious other diseases of the stomach and bowels have this for one of the symptoms ; whether they arise from ruptures, scirrhi, and ulcers, or from mischief done by the violent operation of drastic antimonial, * Sec above, chapter xxi. 22 170 HEBERDEN'S COMMENTARIES. or corrosive mercurial medicines. All these have been the causes of hiccups, which have lasted for months, and for years ; some almost constant, and others with intervals of various lengths. One or two patients have been harassed with them for several months without any other sign of ill health. A hiccup is a symptom of a dangerous nature in acute distempers: it has begun on the first day of a fever, and lasted for the whole seven days, that the patient lived, without yielding to any of the known helps. In other less violent, though at last mortal, fevers it has admitted of no relief for twenty days. The cure of it must either depend on the cure of the primary distemper; or it must be treated with anti-spasmodics, such as moderate doses of opium, or a spoon- ful of the musk julep frequently administered. CHAPTER LXXXII. Sitis. An unquenchable thirst, and, what is often joined with it, a dropsy, or diabetes, are not so much distempers themselves, as attendants upon great disorders of the abdominal bowels ; which most commonly admit of no relief, but end in death. However, the primary malady, though fatal at last, will in some cases be two or three years under- mining the health, before the patient sinks under it; during all which time he is harassed with this most distressing ail, which is usually accompanied with a feverishness, and loss of appetite, and strength, shortness of breath, and other signs of a ruined constitution. Formidable as this symptom is, yet it has not always been fatal; the original distemper in a few instances having admitted, and hap- pily met with a cure. The thirst has been increased by indulging the desire of drinking; and has been relieved by the use of a little nitre. But unless the principal disease can be put into a successful method of cure, it is plain, that this among other symptoms depend- ent upon it, though it may be checked, yet is not likely to be en- tirely subdued. CHAPTER LXXXIII. Spasmus. Involuntary agitations, and cramps or involuntary contractions, in those muscles which should obey the will if much increased, are called convulsions. Every external muscle of the body is liable to spasms, as our senses inform us, and probably all the internal mus- cles likewise. These preternatural contractions of the muscles have sometimes burst a small blood-vessel, and the extravasated blood running under the skin has discoloured it black and blue, and yellow, as it appears when bruised. Cramps and involuntary agitations are familiar to gouty and hys- teric patients, and often forerun and attend palsies, and are the prin- SPASMUS. 171 cipal symptoms of epilepsies and St. Vitus's dance. The causes of them are either in the nerves only of the part affected, or in the brain and spinal marrow. That species of cramp, called chorda penis, is usually occasioned by the acrimony of the venereal virus affecting those particular nerves ; but it may be brought on by other similar local mischief, for I have twice known it without any venereal infec- tion. A perpetual agitation of the left leg and arm arose from a purulent mass, into which the right side of the brain was changed, its natural texture being obliterated. Instances of a like nature with these perpetually occur, whether the irritation of the part, or the pre- ternatural state of the brain and spinal marrow, be owing to any disease, or to some external violence. On the sixth day after the extirpation of a scirrhous testicle, the patient began to complain of a difficulty of swallowing, or rather of a sudden sense of suffocation : and in two days the jaw became im- moveably locked, and the patient soon died. I observed the same happen in an hysteric woman, without any sore or wound. She died about the tenth day ; opium and warm bathing proving ineffectual. After a dangerous fever the sleep of a man was sometimes broken by excessive cramps. Two or three days previous to such a bad night, there used to appear about the middle of the tibia a small soft tumour hardly bigger than a pea ; and by this never-failing sign the approach of the cramp was certainly known. In the fevers of children the face is sometimes drawn to one shoul- der. I have often seen this, but never knew it continue long after the fever was cured. This happens both in continual, and in inter- mittent fevers. A similar circumrotation of the face, sometimes to the right, sometimes to the left shoulder, has continued for a long time in several elderly women who had no other complaint; but in them this involuntary motion has been so little violent, as to be over- powered by a very small force, and therefore has ceased while the head rested upon a pillow. Fevers in the West Indies, as we are told, by some disturbance 'of the brain, give occasion to those very formidable cramps called emprosthotonos, and opisthotonos ; some less derangement has been left by fevers in England, in consequence of which cramps of the legs have returned every night in a most tormenting manner. But the change made in the state of the nerves by a fever has not always in this respect been for the worse ; for the only time that one person was free from spasmodic agitations was during a fever. Sleep favours the access of cramps, as it does of all other nervous complaints; and therefore they are chiefly complained of in the night; they attack some just as they are sinking into sleep, and others just as they are waking at the usual time, or forcibly awake them in what would else have been the middle of their sleep. Acids have some- times brought them on. Slio-ht cramps are cured by altering the position of the limb. JEther has been rubbed into the calves of the legs at bed-time with success. Habitual cramps have yielded to five drops of tinctura thebaica mixed 172 HEBERDEN'S COMMENTARIES. with forty drops of tinctura aszefoetidse taken every night. A fit of the gout has been judged to suspend the power of cramps ; but I am much more strongly convinced, that the gout is apt to breed and foster them. A course of warm bathing effectually cured an obsti- nate cramp, which had for some months kept the body crooked, and one hand immoveably clenched, so that the nails had grown into the palm, and made sores. The waters of Bath have been useful, as it is probable, more on account of their warmth, than of any other qualities. The cold bath has been tried without any benefit. CHAPTER LXXXIV. Sputa Cruenta. A considerable spitting of blood, proceeding not from the stomach with the action of vomiting, nor trickling down from the back of the nostrils, but coming from the lungs, is a very just ground of alarm to the patient. This is very seldom seen in children: many having kept free from this, as well as from the other symptoms of a pulmo- nary consumption, during their childhood, though they were born of consumptive parents, and died of that disease before they were twenty. This complaint has made its first appearance at all times of life from puberty to old age. The danger belonging to it will be greater in proportion to the greater number and degree of the other consumptive symptoms, with which it is accompanied, and to the tenderness of the age at which it comes on. A spitting of blood seems sometimes to be the whole complaint, so that not even a cough shall be joined with it, but the blood will be brought up with as little effort as the easiest phlegm: ' it does indeed most commonly denote an unsound state of the lungs; but from many facts it seem reasonable to infer the possibility of a slight hemorrhage from the vessels of the lungs, or trachea, while the lungs are otherwise in a healthy state, and consequently with as little danger, as from the hemorrhoidal vessels, or those of the nose, espe- cially if it happen at the meridian of life. I have seen a man in good health at seventy, who for fifty years had never been free from spitting of blood above two years together. In others I have known it re- turn every now and then for a long time. In a peripneumony a bloody mucus will be brought up as the patient recovers, and no cough, nor sign of any injury remain. A peripneumony, in which bloody phlegm had been spit up for two or three days, gradually abated, and the patient seemed to be recovered ; but the cough soon came on again, and in a month's time there was a great wasting of the flesh, and a difficulty of breathing, with many signs of approach- ing death: after going into the country, and riding, the patient lost his cough and shortness of breathing, and lived healthy for many years. A very considerable wound may be made in the lungs of a healthy man, as I have known, by a bullet, without either death, or a consumption following. The loose texture of the lungs, and their STEATOMATA. 173 great number of large blood-vessels, together with their constant motion, and the impossibility of any topical application, might make one fear that a large hemorrhage from them could never be stopped, and must prove fatal; yet I have known such a breach entirely cured,* as was probable, from their being no return of spitting blood for near forty years ; and I do not remember, as common as this complaint is, to have seen more than one, who was evidently exhausted by large and repeated returns of it, and might truly be said to have bled to death. A man has survived at least for two years'the loss of a pint of blood from the lungs every day for a month. Not only the common motion of the lungs is borne without much increasing their hemorrhage, but a perpetual sickness and vomiting during a voyage of six weeks did not apparently make a spitting of blood more profuse. These facts may afford some hope in accidents of this kind ; which however most frequently end in a quick consumption, or leave a lasting cough, growing worse every winter, and making the breathing more laborious. Among the notes which I have taken of these cases, I do not find that I have reason to recommend any new remedy, or that I have made any practical remarks upon those which are in com- mon use. The necessity of keeping quiet, and cool, is evident, and therefore of avoiding all strong liquors, high sauces, hot rooms, costiveness, loud speaking, and exertions of all kinds. Two or three large spoonfuls of tincture of roses may be frequently taken with advantage ; and there will sometimes in these cases be occasion for a gentle opiate. If I give so much to the established practice as to allow of one or two small bleedings, where the spitting of blood has not already occasioned too great a loss, I must think a caution neces- sary against large and repeated bleedings which would probably con- spire with the distemper to exhaust the patient. CHAPTER LXXXV. Steatomata. Two children, the one four, the other eight years old, had tumours all over them, some of the size of small nuts, others as large as nut- megs. I judged them to be of a steatomatous kind. One of these children had a voracious appetite: they were both very weakly, and soon pined away, and died. Sottish subcutaneous tumours, between the size of a pea and that of a small nut, without any pain, have been very numerous in the arms only ; and in another they were chiefly seated about the ankles, elbows, and knees, and were suspected to be venereal. In a third, similar tumours continued six years in the arms, and then spontane- ously retreated. They have lasted so long as ten years. • In the second volume of Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge, is given an account of a dissection, where a wound of the lungs had been perfectly healed. — E. 174 HEBERDEN'S COMMENTARIES. The large steatomatous swellings, or wens, are safely cut out, and they seem to admit no other cure. CHAPTER LXXXVI. Stranguria. The strangury, or a frequent and most urgent desire to make water, with excesshre pain in the attempt, is sometimes an attendant upon pregnancy, and usually accompanies diseases of the womb, of the prostate gland, and of the bladder, hard feces obstructing the rectum, and injuries of the urethra from fresh, or frequent, or ill-cured gonor- rhoeas. It has been caused by some sorts of food, and some medicines, as pepper, particularly long pepper, mustard-seed, horse-radish, and other acrid vegetables, and rough cider. This pain has come on from taking six drams of diuretic salts, and very certainly follows the use of spirit of turpentine, one dram of which is on this account a greater dose than can generally be borne. Cantharides are well known to possess the same power beyond all other substances, even applied externally, as well as when taken into the stomach. It is one among the many instances of our imperfect knowledge of the animal economy, that we can by no means understand how the cantharides should pass so quietly without hurting the various passages, and some of them of exquisite fineness, through which they are carried to the bladder, and yet irritate this part in that extraordinary manner, which is too often experienced from the application of blisters. The difficulty of ac- counting for this is increased by our finding, that one blister has sometimes occasioned this irritation, though afterwards in the same person, and the same illness, five blisters applied at once have had no such effect: and what is called a perpetual blister, after it has been kept open seven years without doing the least hurt to the bladder, has all at once, without any apparent reason, affected it so strongly, as to make it impossible to continue the blister any longer. There are persons, who from some unknown peculiarity in their con- stitution, have such a disposition to the strangury, that after the appli- cation of a blister this complaint has continued upon them for several months: others, without any of the known causes, have frequently had returns of it throughout their whole lives from their infancy, par- ticularly in every illness, whatever it were, though no blister had been applied. It is a disorder familiar to elderly persons, both men and women : and it has been suspected, that a tendency to this evil has been created by a gouty habit. No medicines taken into the stomach have appeared to do much good in the strangury. Oil, and gum arabic, may perhaps do a little ; but I have reason to believe, that camphor, like other substances of the same class, will create a dysury, rather than prove its cure. The uva ursi is at best a doubtful remedy, and yet it is capable of doing something to the parts concerned in secreting and containing the urine, STRUMA. 175 for in one patient it was frequently tried, and it always changed the urine to a green colour. Bougies have afforded great ease in difficul- ties of urine from venereal injuries of the urethra, but they have sel- dom effected a complete and lasting cure. Injections of oil into the urethra, sitting over the steam of warm water, warm fomentations of the perinamm, and about the os pubis, have often procured a truce with these pains ; but an opiate clyster made of a quarter of a pint of water, and from twenty to a hundred or more drops of tinctura opii, has most readily cured the strangury arising from a blister, and has been the most certain and expeditious temporary relief in those cases, which admitted nothing further. CHAPTER LXXXVII. Struma. "~ That habit of body is called strumous, or scrofulous, or the evil, in which the lymphatic glands are swelled with little or no pain. This happens most commonly in the neck, and armpits, more rarely in the groin. Those of the mesentery are found liable to the same disorder, and probably all the other internal lymphatic glands. To- gether with these appearances, the end of the nose, and both the lips are apt to swell, and the eyelids are often inflamed, and ulcered. These ails have sometimes followed, or been joined with cutaneous eruptions, and purulent discharges from the ears. Some constitu- tions experience frequent returns of an inflammation of the tonsils, which lasts a few days, not without fever : in others there is an enlargment of them, which sometimes continues for a long time with considerable uneasiness to the patient, and some difficulty of swallowing. Infants and children are particularly subject to strumous disorders, and more especially the weakly with very fair skins. After the age of puberty the tumours of the glands, and the inflammation of the eyelids, usually begin to abate, and in adults often disappear entire- ly ; but in some persons, upon their retreat from the outward parts of the body, they seem to fall upon the lungs, whence arise incurable consumptions. But children are not the only sufferers by this mala- dy ; for I have noted eight or ten healthy persons, in whom the lym- phatic glands began first to be enlarged after the age of thirty, and the swelling in some of them did not show itself till near their sixtieth year. The origin of this mischief in these adults was probably to be found in the unwholesomeness of their diet, or situation. The use of a very hard water was suspected to have made one of them scrofulous; for he began to be so after using it constantly for a few years, and continued so long as he used it, but upon leaving it off, all the scro- fulous appearances left him. It is most probably owing to some bad quality of the water, that swellings of the throat are endemial in some parts of England, and notoriously among the inhabitants of the Alps ; though I by no means think it owing to the use of snow-water, to 176 HEBERDEN'S COMMENTARIES. which it has been attributed : for I believe, on account of its great purity, this would be one of the best remedies they could employ.* Beside these swelled glands, which make one species of the evil, there is another, which is called the Joint evil, which has begun in the hands, or elbows, or feet, with a small tumour situated so deep, that the bones are often affected. These have continued two or three years, before they have come to ulcers, which have been of such a malignant nature, as at length to make the hands or feet almost use- less, or to make the fingers and toes fall off. Are the diseases of the head of the thigh-bone, and its socket, and also what is called the white swelling of the knee, to be referred to this class? This seems not unlikely, as they have been found joined in the same person with the usual marks of an inveterate scrofula. Some strumous appearances have shown themselves not long after the measles and small-pox, and this has created a suspicion, that this alteration of the health was to be attributed to some relics of those diseases : but this has happened too seldom within my observation to give any just grounds for such an opinion, which perhaps has been entertained the more readily, because the patients, or their friends, were unwilling to think the scrofulous complaints hereditary, or con- stitutional. The scrofula, and lues venerea, when they meet, seem greatly to exalt the malignity of each other. The swellings of the lymphatic glands in the neck, and armpits, have continued above twenty years without any other variation, than being a little enlarged upon catching cold : but this is extraordinary, and happens but seldom : they more usually either lessen by degrees, and vanish in not many months, or in a very few years ; or else in- flame, and suppurate. The larger break into smaller parts with a slight degree of itching in the skin previously to their going away; and the smaller first grow softer, and so gradually sink down, and are reduced to their natural size ; instances of all which are very common. When, instead of dispersing, these tumours inflame and grow red, they are a long time in coming to a sore, in which state they are slowly dissolved into an imperfect pus, and afterwards heal. These sores have never within my observation shown a disposition to turn can- cerous in children, and only in two or three adults. I never saw any occasion for using poultices, plasters, or warm coverings to strumous swellings. They cannot be wanted to miti- gate the pain, because it is so inconsiderable ; and if it be meant to disperse them by plasters, it may be doubted whether any have a power of this kind ; but if the application be intended to make them * The inhabitants of Rheims had been so afflicted with strumous diseases, that they maintained an hospital for the sole purpose of curing such patients. They then made use of no other water than what they had from wells. After a machine was constructed, which brought the water from a neighbouring river, and distributed it into all quarters of the city, it was observed that scrofulous disorders became less common ; and in the space of thirty years the number of these patients was reduced to one half of what it had usually been : it continued to decrease so fast, as to give occasion for thinking, that the greater part of the revenues of the hospital might be applied to other purposes. — Soc. Royale de Medecine, vol. ii., Hist., p. 280. TENESMUS. 177 suppurate, it is doing that, which too much pains can never be taken to prevent; for they cannot terminate in a worse manner. If this event cannot be hindered, and the glands spontaneously tend to become ulcerous, they should be suffered to break of themselves without the help of a knife or a caustic; and the mildest defensa- tive plaster is all the further care which they require. The scrofu- lous inflammations of the eyelids, and eyes, sometimes make bleed- ing necessary ; and they have been much more benefited by leeches, than by taking away blood in any other manner : two or three may be put to each temple once or twice a week for a considerable time. Many external applications to the eyes are recommended, all which have been often found of very little service, except soft cataplasms put between two pieces of fine linen, and so applied to the eyes, and touching the edges of the sore eyelids every night with some softened animal fat, which will hinder their being glued together in the night; for the force used to open them in a morning keeps them constantly raw and sore. Mercurial medicines have been judged to hurt, rather than to help scrofulous patients; and perhaps strumous distempers have been aggravated by the accession of a venereal infection, chiefly on ac- count of the preparations of mercury which these require. Sea- water, internally and externally, extract of hemlock, bark infused in purging waters, or taken in substance at night, while purging waters, or salts, are used in the morning, burnt spunge, sal sodae, issues, and perpetual blisters, are the principal means which have been recommended as alteratives of a strumous habit; all which, as experience has taught, may be employed with safety ; but the repu- tation of their efficacy is far from being fully established. Where the patient has not perseverance enough to continue the use of any of these for a proper length of time, he may do himself some, and I believe considerable service, by a temperate course of life, and by drinking no other water than such a pure one as that of Malvern. CHAPTER LXXXVIII. Tenesmus. A constant needing, or wanting to go to stool, though little or no feces could be voided, has been owing to the following causes • hard feces, which had loaded the rectum, and which could not De expelled without assistance ; a scirrhus of the womb, of the rectum, or of the prostate gland ; a stone in the bladder ; a strangury, par- ticularly one brought on by cantharides; and a weakness of the sphincter ani left by an apoplexy, or a difficult labour. It is usually troublesome for a little while after a dysentery; and has accompa- nied the colica Saturnina, and a prolapsus of the inner coat of the intestine. A tenesmus is usually increased by standing or walking, and re- lieved by sitting. When it is merely owing to acrimony, an opiater 23 178 HEBERDEN'S COMMENTARIES. clyster will be the best remedy. In other cases the relief of this uneasy sensation must depend upon the cure of the original disease, of which it is a symptom. CHAPTER LXXXIX. Testiculus. Besides tumours of the testicles from external, or venereal inju- ries, they have been found joined with an intermittent fever, coming on and going off with every fit, and finally ceased upon the cure of the intermittent: this has happened more than once. A common cold has had a similar effect upon several persons. A scirrhous prostate gland has made the testicles swell; which also is no very uncommon consequence of stones, and other affections of the kid- neys. Without any manifest cause a swelling has begun in one of the testicles, and after continuing a few months has spontaneously subsided. A tumour of them has at other times slowly increased for many years, and at last made the whole testicle scirrhous, which has been twenty years before it became cancerous and fatal. A fistu- lous sore has formed in such a testicle, and has long harassed the patient. Purges, except very gentle ones, have been at least useless. Poul- tices are necessary when the pain is considerable. Whether there be pain or swelling, a bag-truss is of indispensable use to suspend the scrotum. There is no cure for a scirrhous testicle, but castra- tion ; and this may be safely performed, if the spermatic cord be in tolerable order; but where this too is diseased, the case admits of no cure. The hydrocele is inconvenient, but void of danger ; and may be sufficiently relieved, without pain or hazard, by tapping, as often as there is occasion. An operation is sometimes performed in the hydrocele, which makes a lasting cure. CHAPTER XC. Torpor. A numbness, or sense of tingling in a limb, which is commonly called its being asleep, has been experienced in every part of the body, but chiefly in the limbs, and particularly the extremities. It is a half loss of the sense of feeling, and is extremely common, though a total loss of it be so rare even in the most hopeless palsies. A numbness, like a cramp, has been either a slight complaint brought on by an inconvenient posture, or other trivial causes, unat- tended with any ill consequences, and presently removed ; of else it has arisen from that preternatural state of the nerves, which is incon- sistent with tolerable health, or, it may be, with life, and has been the forerunner of convulsions, palsies, and apoplexies. The old seem most subject to it, and both sexes equally; in youth, females have TREMOR. 179 oftener been sufferers than males. Where a torpid state of any part has not been constant, it has been found to come on chiefly in the night, owing partly to a long continuance of the same posture, and partly to sleep, which favours the access of all disorders in which the nerves are more immediately concerned. Numbnesses are familiar to broken constitutions, and such as have been derived from paralytic parents. They have been the forerun- ners, the attendants, and followers of palsies, and apoplexies, and are commonly joined with other symptoms of these maladies. This very frequently makes one of the numerous complaints, which are heard of among hypochondriac and hysteric patients, and has conti- nued in them and others not only for many months, but often for many years, and then has gone off without having done any mis- chief to the health. The whole left side has been benumbed for five- and-twenty years. The true nature and tendency of a numbness may be best known by its attendant circumstances; for if it be associated with other pa- ralytic symptoms, and affect a considerable part of the body, espe- cially in persons derived from paralytic parents, no doubt can be made of its betokening mischief, and the proper preventives of pal- sies should be employed. But if a torpor should affect only a small part, as one or two fingers, or toes, and be united with no other symp- toms, or only such as are common in hypochondriac disorders, the less notice the patient takes of it, the happier he will be. But if there should be reasons for endeavouring to cure this more innocent species of the complaint, blisters, and warm bathing, have been found the most serviceable means; cold bathing, and bleeding, have been found prejudicial; the gout has been useless ; and as for electricity, its virtues have not yet been sufficiently ascertained. CHAPTER XCI. Tremor. A trembling of the hands, or a shaking of the head, may be judo-ed to have some alliance with paralytic and apoplectic maladies ; yet°it has been found by experience, that such a tremor has often continued for a great part of a person's life, without any appearance of further mischief; and therefore, if it have a tendency to palsies, it is a very remote one, and the inconvenience is far more consider- able than the danger. Hypochondriac persons are troubled with frequent fits of it; hard drinkers have it continually ; and some de- grees of it usually attend old age. 3 This like other affections of the nerves, is greatest in a morning, and is aggravated by any disturbance of mind. Coffee and tea make the hands of some persons shake ; and yet I have known strong cof- fee drunk every day for forty years, by one who was remarkable for the steadiness of his hands even in extreme old age. There are many others who know no such ill effect from these liquors; and indeed, 180 HEBERDEN'S COMMENTARIES. if it were general, few Chinese, and Turks, would escape it; 1 their history does not acquaint us, that these people are more subj to tremors, than those of other nations. If any medicines are wanted, they must be such as are found s viceable in paralytic and hypochondriac complaints. CHAPTER XCII. Tussis. A coug-h seems to have been sometimes occasioned either by an acrimonious, or a too copious defluxion on the trachea, without any material, or permanent injury of the lungs; or merely by disorders of the stomach and bowels, as hath appeared upon dissections, exam- ples of which are often seen in children with worms, and swelled mesenteric glands. In cases where the lungs themselves have been diseased, it is observable that they are sometimes in a disposition to let the mischief spread in a rapid manner all over them, and in a very short time become a fatal consumption ; while in other instances the injured part of the lungs has seemed to remain in the same state for twenty, forty, or even sixty years, with very little inconvenience beside the cough, so that the patient has grown fat with it; or else the disease of the lungs has spread so slowly, that though the cough has become a little worse every winter from youth to old age, yet it has not been till towards the end of a long life, that the lungs have become so diseased, as to do their duty with that difficulty, which is called an asthma. Even an ulcer of the lungs, as was adjudged from the blood and purulent liquor spit up, has for a considerable time kept itself confined within the same bounds. In a few cases the ulcer has probably been seated in a capsula, which has at last been coughed up with great efforts, and some danger of suffocation; after which there has been a total cessation of all the complaints, the sore being in all probability entirely healed. In hysteric, and convulsive diseases, arising from some disordered state of the whole system of nerves, those serving to respiration have among the rest been dis- turbed so as to occasion violent coughs, without any more injury to the lungs, than the convulsions of the limbs, or body, occasion in those parts, which they have seized. These coughs, and those aris- ing from defluxions upon the lungs, are attended sometimes with an unusual noise, and are generally much stronger, than consumptive eoughs are, not only in their beginning, but even in their advanced state. The same is likewise the case with those coughs, which are owing to some hard body fallen into the trachea. I have seen a vio- lent, and almost perpetual cough, arising from a bone fixed in the windpipe, which had lasted some months with an unusual sound, and presently ceased upon coughing up the bone. Coughs have molested some persons alternately with ophthalmies, the gout, scald head, and other cutaneous disorders. It must be re- membered, that in all long coughs there is danger of a consump- tussis convulsiva. 181 tion, and therefore a cool regimen is of indispensable use, in order to keep the lungs in that state, which is most likely to hinder the sound parts from being infected by the diseased. There have been too many examples of coughs remaining in a tolerable state for twenty years, and which with proper care might have remained so for twenty more, which have by mismanagement, or catching cold, been joined by all the symptoms of a quick consumption, soon after terminating in death. Hence arises a difficulty of deciding, whether a cough be a consumptive one : most coughs naturally tend to a pul- monary phthisis ; and though the tendency be sometimes so strong, that there is no hazard of being mistaken in pronouncing the cough consumptive, yet in many instances no physician can prognosticate the event, unless he be able to predict also what the patient's man- ner of living will be, and whether he will always escape violent colds, and peripneumonies. Abstemiousness, change of air, and a judicious use both of bleed- ing and of opium, have proved the best means of soothing a trou- blesome cough, and of hindering it from becoming a dangerous one. CHAPTER XCIII. Tussis convulsiva. The hooping-cough is most common among children, and is un- doubtedly contagious ; it is a tedious disorder, lasting often for several months; and though sometimes slight, yet in some children it proves fatal. An inundation of phlegm, or a vomiting, the clear- ness of the intervals, and the violence of the fits, may generally dis- tinguish it from a common cough in the very beginning ; but after- wards it cannot be mistaken, when the expiration in coughing con- tinues so long, that they can hardly recover the power of drawing in their breath, which is done at last with a peculiar sound, called hooping ; and this principally characterizes this mstemper. A child has had one of these coughs three months before the hooping came on. The violence of the cough sometimes makes the nose bleed, and the face blackish, and has strained the eyes so as to do them a lasting injury. It does not usually attack a person more than once ; but to this I have heard some few exceptions among those whom I have attended in it, of whom more than one have assured me they had been ill of it before. Old persons are less liable to this malady, but by no means ex- empt from it: I have seen it in a woman of seventy, and in a man of fourscore. A child has some notice of the approach of a fit, so as to be able to run to his nurse, or mother, before it begins; but adults are, as it were, overpowered at once upon the access of the fit, so that they fall down instantly, as in an apoplexy, but very soon come to themselves : this is a distinguishing symptom of the disease in those who are grown up ; and if they have not before been subject to a cough, and have lately been in the way of catch- 182 HEBERDEN'S COMMENTARIES. ing this distemper, the circumstance of their falling down in this manner may take away all doubt about the nature of their illness. Flatulence in an extraordinary degree often accompanies this cough. Experience has instructed us, that a change of air is of singular use in abating the force, and shortening the stay of this distemper. The stomach is so much disordered in it by being overloaded with phlegm and oppressed with wind, that it seems very reasonable to relieve and strengthen this part by the help of rhubarb and bitters. The hooping-cough has so much the nature of a convulsion, that a prudent use of opium, together with musk, lac ammoniaci, and vinum antimonii, might probably be beneficial; but I have not seen such undoubted success from these medicines, as to be confident of their virtues. As for the numberless specifics, which are every where to be met with, I have nothing to say in their favour from my own observation. CHAPTER XCIV. Valetudo conquassata. A dangerous disease, or great decay of the parts necessary to life, occasions what is called a broken state of health ; by which is meant an assemblage of many or most of the following complaints: A paleness, or sallowness of the countenance ; a bloated face; thirst; shortness of breath ; palpitation of the heart ; flatulence ; loathing of food ; sickness ; frequent making of water ; incontinence of the stools, and of the urine ; swelling of the legs ; wandering pains; spasms ; wasting of the flesh ; weakness ; lassitude ; itching of the skin ; tremblings ; numbnesses ; feverishness; languor; faintings; sleepiness in the day-time; want of sleep at night; forgetfulness. CHAPTER XCV. Variola. The experience which I have had of inoculation, does not enable me to add any thing to what has been already established in relation to its utility, or the management of the inoculated. %1 am sorry to have found, that this operation has not always secured the patient from having the small-pox afterwards, if the eruption have been im- perfect without maturation. I attended one in a very full small-pox, which ran through all its stages in the usual manner ; yet this person had been inoculated ten years before, and on the fifth day after in- oculation began to be feverish with a headache, followed by a slight eruption, which eruption soon went off without coming to suppura- tion ; the place of inoculation had inflamed, and remained open ten days, leaving a deep scar, which I saw. By some accident, mo§t of the notes are lost, which had been made during my attendance on a great number of patients in the un- f VARIOLA. 183 inoculated small-pox; therefore I shall not attempt to give a full history of this distemper, but confine myself to the relating of such observations as are justified by the few remaining papers. Many instances have occurred to me, which show that one who has never had the small-pox, may safely associate, and even lie in the same bed with a variolous patient, for the two or three first days of the eruption, without any danger of receiving the infection. One woman continued to suckle her infant for two days after the small- pox had begun to appear upon her; and the child being then re- moved escaped the distemper for that time, but was unquestionably capable of being infected, because he catched it about a year and a half after. Parents have several times judged it proper, when one of their children has fallen ill of the small-pox, not to send those away, who had not had this distemper, but to let them all continue together in the same house, and often in the same chamber. About the sixth day after the distemper had arrived at its height in the sick child, the others have for the most part begun to complain; and therefore it is probable that this is the time, when the distemper begins to be communicable ; the infection lying dormant about the same number of days, that it does in those who have been inoculated. But there are much greater varieties in this way of taking the small-pox, than by inoculation, accordingly as persons go more or less into the way of receiving the breath of the sick person, or of touching things daubed with the variolous matter. Two children were constantly kept in the sick chamber, and yet did not fall ill till a month after; and there are not a few examples of persons, who have seemed to be equally exposed to the infection, and yet have received it at different times. An excruciating pain in the loins has never failed to be succeeded by a bad small-pox, and the more violent the pain the greater has been the danger; it is much safer to have it between the shoulders; but it is safest to have none in any part of the back. Excessive vomiting for the whole time before the eruption is sel- dom followed by a mild disease ; and if the vomiting be continued after the eruption is completed, the patient's life is in great danger, even though the small-pox be not confluent, as I have seen more than once. It is very common to have convulsions precede a mild small-pox in children, and the same has been known in some adults with as prosperous an event. The variolous infection does some force*to the vessels, which sup- ply the menstrual discharge in women ; and in the worst sort of small- pox this evacuation has come on out of its regular course two days be- fore the small-pox has begun to show itself, and has continued to flow in an excessive manner. It has sometimes appeared before its re- gular time, together with the eruption. But what I have more usu- ally observed, is, that this uterine flux in almost all female patients has begun as soon as the eruption was completed, and it has continued 1S4 HEBERDEN'S COMMENTARIES. from one day to five. This discharge, though sometimes much greater than the natural one, does not seem to check the progress of the small-pox, nor to sink the patient's strength, and therefore very- little pains need be taken to stop it, even though we had any ready and innocent way of doing it. That very formidable symptom, bloody urine, has come on about the fifth day from the first sickness; the eruption in the meantime has hardly risen above the skin, chiefly showing itself in purple spots and blotches, and resembling variolous pimples only in very few places. The stools are likewise bloody ; the very tears have been like lotura carnium ; and if a small scratch has any where been made in the skin, the blood has for many hours continued to ooze out, and has hardly been stopped. This hopeless state has been terminated by death in three or four days after the eruption ; nor have I remark- ed one exception. But the urine may be discoloured in the small- pox, and have a hue as dark as coffee, even where there is no rea- son to suspect its proceeding from gravel, and yet afford no ground for alarm, if not jqined with other bad symptoms. In a middling sort of small-pox, the urine became black on the fourth day of the eruption, and continued so for four days. In another, the same black urine began on the second day of the sickness, having a sediment like coffee-grounds for two days. Both these patients went on pros- perously without any other bad or unusual symptom. The pustules have sometimes shown themselves not very different from their gene- ral appearance in a middling sort, but the interstices have been filled with small round purple spots, and the distemper has been fatal on the third day of the eruption. It has been remarked above, that the variolous virus has a peculiar ef- fect in exciting the uterine flux, and upon this property of it perhaps de- pends its well-known eff'ectupon pregnant women, who usually miscarry on the seventh or eighth day from the first eruption, and in a day or two after die. The foetus of this abortion I have often examined with great attention. The skin of it has been much discoloured, in some parts of a dirty red, in others blackish, and in a few places of a na- tural colour; but I could never see any appearance of a variolous eruption I have known a very few pregnant women, who have gone through this distemper without miscarrying, and have afterwards been brought to bed at the natural time ; but I could never see upon these chi dren any such marks as might be left by a variolous eruption ; and I am well assured, that such children have afterwards had the small-pox. A young girl was opened, who died full of the small-pox, and I observed that none *f the bowels or internal parts showed the east marks of their having any variolous pustules : now the foetus in utero seems to be so much in the same state with the bowels, that if these are never the seat of the pustules, it is hardly to be einected that any should be found upon the foetus. Y expected A great shortness of breath coming on about the fifth dav of thP eruption, scarcely leaves any hopes thSt the patient will sur/ive he distemper, the difficulty of breathing is sometimes so greaTas not to VARIOLjE. 185 suffer the patient to lie down, or to have breath sufficient for speak- ing a common sentence. A sudden sinking of the swelling in the face, so that the eyes can be opened ; an abrupt stoppage of the spitting ; a frequent wanting to niake water, and making very little at a time ; a total absence of all fetor ; and great shiverings; though they be very dangerous signs, yet have been seen without proving fatal. Watery bladders, full of a yellow serum, like those raised by blis- tering plasters, rise up among the pustules in some kinds of the small- pox, and may show an irregularity and malignity; but such patients have recovered. In the decline of the distemper, when most of the scabs had fallen off, I have twice seen a few pimples with watery heads, without any redness or inflammation, which afterwards maturated and resembled the true small-pox. These pustules were only in the soles of the feet and palms of the hands. In one child the pocks were large, and few, for four days, and then there was an eruption of very small and nu- merous pustules, from which the child with difficulty escaped. In another there were a few pocks, and the child notwithstanding was very restless and oppressed; after these were dried, others broke out, and came to maturation ; and even afterwards one or two made their appearance. The child died, though all the pocks, if they had ap- peared, were so few, that I never saw any other person die, who had not more. These are the only instances, which have occurred to me something like, what is often talked of, a second crop. It has happened to three variolous patients in the decline of their distemper, when they were thinking of having a little meat allowed, and of taking, as usual, some purging medicine, that they have sud- denly become gloomy and suspicious, and in forty-eight hours have died raving mad. An excessive spitting, which proves so beneficial in the confluent small-pox, has in a few persons continued for several days after the decline of the distemper, in a degree equal to a common salivation, and no harm has ensued. The milk of a woman, who suckled a child, began to lessen at the height of the small-pox, and soon after went quite away ; but after a few days it returned as plentifully as ever. In all distempers, it is considered as a favourable circumstance, that the person is free from all other complaints, with a constitution na- turally good, and unimpaired : for when there is nothing to divert the powers of life from opposing the present illness with their whole force, a happy event may reasonably be expected: and yet a complication of the small-pox with other formidable maladies, has in several in- stances not exalted its malignity, or produced a bad sort, nor disabled the patient from struggling through it in the usual manner. Venereal distempers have often been joined by a mild small-pox ; and in a worse sort they have not at all added to the usual danger or sufferings of the patient. Others have catched the small-pox when they were dying of scrofulous consumptions ; but have still had all the necessary 24 186 HEBERDEN'S COMMENTARIES. strength to recover unhurt from the new distemper, and they have not appeared to die a day the sooner of their old one. In a large town, at a time when agues were epidemical, it chanced that the small-pox was brought in, and many catched it before they were cured of their agues. It was observable, that the ague stopped spontaneously in these patients, as soon as the small-pox fever began, and constantly returned after the small-pox was over and one or two purges had been taken. The two distempers seemed to have no other influence over one another. Mankind has hitherto been blessed with specifics for very few dis- tempers. The small-pox is one among many others, the proper remedy for which, if there be one, is left to be found out by the saga- city, or good fortune, of future physicians. Sanguine expectations have been entertained of the great service which the Peruvian bark, and the preparations of antimony, and of mercury, would do in op- posing the variolous virus. But such hopes have upon trial all dwin- dled away, and left us just where we were. The method therefore of treating the small-pox will not differ from that which is contained in the general doctrine of the regimen and diet of the sick: and the troublesome symptoms which may arise, must be relieved, and the functions of life kept as much as possible in their natural state, by the same means which are used in any other fever. Costiveness in par- ticular is as hurtful in the variolous fever, as in any other: which I mention, because the contrary opinion formerly prevailed, and is hardly yet quite worn out. CHAPTER XCVI. Variola Pusilla. The Chicken-Pox. The chicken-pox and swine-pox differ, I believe, only in name: they occasion so little danger or trouble to the patients, that physi- cians are seldom sent for to them, and have therefore very few oppor- tunities of seeing this distemper. Hence it happens that the name of it is met with in very few books, and hardly any pretend to say a word of its history. But though it be so insignificant an illness, that an acquaintance with it is not of much use for its own sake, yet it is of importance on account of the small-pox, with which it may otherwise be confounded, and so deceive the persons, who have had it, into a false security, which may prevent them either from keeping out of the way of the small-pox, or from being inoculated. For this reason I have judged it might be useful to contribute, what I have learned from experience, towards its description. These pocks break out in many without any illness or previous sign : in others they are preceded by a little degree of chillness, lassi- tude, cough, broken sleep, wandering pains, loss of appetite, and feverishness for three days. In some patients I have observed them to make their first appear- VARI0L7E PUSILLA ; THE CHICKEN-POX. 187 ance on the back, but this perhaps is not constant. Most of them are of the common size of the small-pox, but some are less. I never saw them confluent ; nor very numerous. The greatest number, which 1 ever observed, was about twelve in the face, and two hundred over the rest of the body. , On the first day of the eruption they are reddish. On the second day there is at the top of most of them a very small bladder, about the size of a millet-seed. This is sometimes full of a watery and colourless, sometimes of a yellowish liquor, contained between the cuticle and skin. On the second, or, at the farthest, on the third day from the beginning of the eruption, as many of these pocks, as are not broken, seem arrived at their full maturity ; and those which are fullest of that yellow liquor, very much resemble what the genuine small-pox are on the fifth or sixth day, especially where there hap- pens to be a larger space than ordinary occupied by the extravasated serum. It happens to most of them, either on the first day that this little bladder arises, or on the day after, that its tender cuticle is burst by the accidental rubbing of the clothes, or by the patient's hands to allay the itching which attends this eruption. A thin scab is then formed at the top of the pock, and the swelling of the other part abates, without its ever being turned into pus, as it is in the small- pox. Some few escape being burst; and the little drop of liquor contained in the vesicle at the top of them grows yellow and thick, and dries into a scab. On the fifth day of the eruption they are almost all dried and covered with a slight crust. The inflammation of these pocks is very small, and the contents of them do not seem to be owing to suppuration, as in the small-pox, but rather to what is extravasated immediately under the cuticle by the serous vessels of the skin, as in a common blister. No wonder therefore that this liquor appears so- soon as on the second day, and that upon the cuticle being broken it is presently succeeded by a slight scab: hence too, as the true skin is so little affected, no mark or scar is likely to be left, unless in one or two pocks, where, either by being accidentally much fretted, or by some extraordinary sharpness of the contents, a little ulcer is formed in the skin. The patients scarce suffer any thing throughout the whole progress of this illness, except some languidness of strength and spirits and appetite, all which may probably be owing to the confining of them- selves to their chamber. I saw two children ill of the chicken-pox, whose mother chose to be with them, though she had never had this illness. Upon the eighth or ninth day after the pocks were at their height in the children, the mother fell ill of this distemper then beginning to show itself. In this instance the infection lay in the body much about the same time that it is known to do in the ^Remedies are not likely to be much wanted in a disease attended with hardly any inconvenience, and which in so short a time is cer- tainly cured of itself. Tne principal marks, by which the chicken-pox maybe distinguish- ed from the small-pox are, 188 HEBERDEN'S COMMENTARIES. 1. The appearance on the second or third day from the eruption of that vesicle full of serum upon the top of the pock. 2. The crust which covers the pocks on the fifth day ; at which time those of the small-pox are not at the height of their suppuration. Foreign medical writers hardly ever mention the name of this dis- temper ; and the writers of our own country scarce mention any thing more of it, than in name. Morton speaks of it as if he supposed it to be a very mild genuine small-pox. But these two distempers are surely totally different from one another, not only on account of their different appearances above mentioned, but because those, who have had the small-pox, are capable of being infected with the chicken- pox ; but those, who have once had the chicken-pox, are not capa- ble of having it again, though to such, as have never had this dis- temper, it seems as infectious as the small-pox. I wetted a thread in the most concocted 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 an infection. From the great similitude between the two distempers, it is probable, that, instead of the small-pox, some persons have been inoculated from the chicken- pox, and that the distemper which has succeeded, has been mistaken for the small-pox by hasty and unexperienced observers. There is sometimes seen an eruption, concerning which I have been in doubt, whether it be one of the many unnoticed cutaneous diseases, or only, as I am rather inclined to believe, a more malignant sort of chicken-pox. This disorder is preceded for three or four days by all the symp- toms which forerun the chicken-pox, but in a much higher degree. On the fourth or fifth day the eruption appears, with very little abate- ment of the fever ; the pains likewise of the limbs and back still continue, to which are joined pains of the gums. The pocks are redder than the chicken pocks, and spread wider, and hardly rise so high, at least not in proportion to their size. Instead of one little head or vesicle of a serous matter, these have from four to ten or twelve. They go offjust like the chicken-pox, and are distinguisha- ble from the small-pox by the same marks ; besides which the con- tinuance 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 happens in the small-pox. Many foreigners seem so little to have attended to the peculiar characteristics of the small-pox, particularly the length of time, which it requires to its full maturation, that we may the less wonder at the Prevailing opinion among them, that the same person is liable to have it several times. Petrus Borellus* records the case of a woman, who had this distemper seven times, and catching it again died of it the eighth time. It would be no extravagant assertion to say, that here in England not above one in ten thousand patients is pretended to have had it twice ; and wherever it is pretended, it will always be as likely that the persons about the patient were mistaken, and sup- * Hist, and Obs. Rar. Med. Phys., ccntur. iii., obs. 10. VENTRICULI MORBI. 189 posed that to be the 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. CHAPTER XCVII. Ventriculi Morbi. One among the many disorders of the stomach is a disagreeable sense of acidity rising from it, which is accompanied often with pain, or a sort of anxiety worse than pain, sickness and vomiting, a sense of weight, voraciousness in some, and loss of appetite in others, flatu- lence, and distension of the stomach, headache, great quantities of phlegm, and a waking out of sleep with some degree of terror. If we were to reason upon chemical principles, nothing seems more practicable, than to neutralize, and subdue an acid, to which we can immediately add whatever we think proper ; but the animating prin- ciple makes so much difference between a living stomach and an inanimate vessel, that this, which appears easy in theory, has been found very difficult in practice ; and persons have been teased with this complaint for twenty years, without being able to find a cure. Lime water, magnesia, testaceous powders in the quantity of an ounce every day, and alkaline salts, have in several instances been tried in vain. Milk, vegetables, fish, fat of any kind, a full meal, especially with any exercise soon after it, have generally disagreed with stomachs disposed to acidities, which they have much increased. Acids them- selves have not always been hurtful, but have sometimes proved a relief. Emetics and Bath waters have succeeded with some and failed with others. Large quantities of testaceous powders, and rhu- barb, have been the most generally useful; and a costive habit ot body has been always prejudicial. After trying a variety of means for many years upon the most unconquerably acid stomach which 1 ever knew, the method, in which the patient settled, and which alone was able to keep the complaint in tolerable order, was he taking one ounce of testaceous powders every morning and drinking a gallon of warm water, as an emetic, every night.; which course, with a little rhubarb occasionally, was pursued for several years. The heartburn is an usual companion of acidities in the stomach, differing very little from them, either in its causes, or cure and h s been as^obstinate in resisting all sorts of medicines It has been at- tended with hiccups, eructations, and an immoderate flow of sah*a. Durino-pregnancy it is apt to be uncommonly troublesome, and is often addedSo the evils of the gout, and sometimes to those of the laundice A disposition to it seems to be borne with some persons who lave been teased with this uneasy sensation for the greatest part ot their lives. Cutaneous eruptions, and the hear burn, have alternately harassed some persons. One woman, while she was 190 ITEBF.RD-F.N'S COMMENTARIES. breeding, could find no relief for a violent heartburn from any of the usual remedies, and was at last cured by elixir of vitriol. § 2. Ventriculi Dolor. Inflammations, or cancerous scirrhi of the liver, spleen, and pan- creas, with all other kinds of pains between the breast and the navel, are usually referred to the stomach ; and beside the disorders, which properly belong to it, and have their origin there, it sympathises with all parts of the body in many of their ails. The gout, and perhaps the rheumatism, wandering pains, and those that are fixed, all sores and cutaneous diseases, have frequently either deserted their first seats and fallen upon the stomach, or else have drawn it to suffer together with the parts first affected. With regard to giddiness, and headaches, though they be sometimes the causes, yet they seem oftener the effects of stomach disorders. The diseases of the womb injure the stomach in a very remarkable manner; and it rarely escapes without pain, or sickness, whenever any of the various irregularities of the menstrua are complained of. It is equally a sufferer in hysteric and hypochondriac maladies, in all great perturbations of mind, and in worms, even those which are generally found only in the great intestines. Where there is no reason to suspect and provide against any of these causes, and where the pain does not proceed from any poison, or improper food ; if it be very excessive by fits with intervals, espe- cially very long ones, of perfect ease and blameless health, there we have the greatest reason to believe it owing to gall-stones. I have noted a very considerable number of persons, who for many years (some not less than twenty) had been subject to returns of pains in what is called the pit of the stomach, and at last the appearance of the jaundice clearly pointed out their origin, or the voiding of a gall- stone has entirely removed them. In others, after a fit of the jaun- dice, the same pain which preceded it, and had given the patients too much reason not to mistake it, has continued to torment them at irregular times, sometimes without a yellowness, and sometimes with, for at least twelve years. Some have been subject for a great part of their lives to a moderate or dull pain in the side, or about the stomach, which, as I judged from the appearances after death, upon their being opened, was most probably owing to some gentler move- ments of a gall-stone. The great varieties of pains attributed to the stomach, and the dpfferent causes of those which truly belong to it, will account for the variety of their concomitant symptoms, and the different events of similar treatments. Bath, wine, hot medicines, a full stomach, a vegetable diet, cathar- tics, emetics, the state of pregnancy, a fit of the gout, acids, worm medicines, blisters to the region of the stomach ; all these have in many instances been found to do good, to do harm, and to do no- thing at all. After due attention has been used to discover the true nature of the pain, if there be reason to think that its origin is in MORBI LIENIS. 191 the stomach, and that it does not proceed from any inflammatory or scirrhous affection, an emetic is generally useful at first, and after- wards the method of cure, which has often succeeded, is either the drinking of Bath water, or a daily use of some of the bitter and aro- matic simples, joined with as much rhubarb, or aloes, as may be necessary to keep off all tendency to costiveness. A tea-spoonful of some aromatic tincture has likewise been taken with great advantage in a little water immediately after dinner. A great variety of such medicines is to be found in all pharmaco- poeias, out of which such may be chosen as will suit most stomachs, and hardly offend any palates. They are of frequent and very im- portant use in the practice of physic, not only because the disorders of this part are far more common than those of any other, but because in unknown distempers, or in those where there is no good to be done by evacuations, and for which we have no specifics, we can only aim at putting the general health into the best state possible, the prin- cipal means of doing which will be to strengthen the stomach. § 3. Morbi Lienis. A man in his fiftieth year began to lose his flesh and strength with some degree of fever. He sometimes felt slight shiverings, and sometimes very strong ones, returning irregularly during the whole illness. His appetite was lost, but he had no vomiting. The stools were regular till the two last months of his life. The urine was in a natural state. The pulse was very rarely too quick. There was no tension of the belly. In the second month of his illness he had an excessive pain in his stomach. Pains of the loins, hips, and back, would come on suddenly, without continuing above half an hour. For a few days his right hand was swelled, and in pain ; and for two days the calf of the left leg was too painful to bear being touched, but without any heat, redness, or swelling. He complained chiefly of the right side of the belly. During the last two months of his life he was harassed with an unconquerable diarrhoea. This illness proved fatal about the sixth month. A large ulcer was found in one part of the spleen, and the rest of it seemed rotten. An adhesion had been formed between the spleen and peritonaeum. No other parts were distempered. A man forty-two years old had complained for several months of loss of appetite, flatulence, white stools, dark coloured urine, fre- quent bloody stools, tenesmus, perpetual nausea and attempts to vomit, chiefly in an empty stomach, excessive restlessness, want of sleep, bleedings at the nose, thirst, and light-headedness, though the fever was moderate. At last a sudden vomiting of blood came on ; which returning in five hours, put an end to his life. The spleen was found of an uncommon magnitude, but without hardness; the inside of it was all dissolved into a bloody sanies. The glands of the mesentery were full of the same matter. The liver was sound. The portion of the stomach nearest to the spleen was inflamed; and there were signs of inflammation in many parts of the intestines. 192 HEBERDEN'S COMMENTARIES. A woman was languishing for six months with a failure of appe- tite, and a swelling of the left side of the belly. There then came on sickness, and pain of the stomach, a total loss of appetite, a diar- rhoea with great pain, which could not be stopped, and extreme rest- lessness, which lasted about six months longer. The spleen weighed fifty-two ounces, but was not ulcered, or scirrhous. The intestines were in a natural state, and there was no water in the abdomen. § 4. Morbi Pancreatis. A woman had long been afflicted with a pain, as she said, ot her stomach ; which was excessive for the last year of her life. She had no appetite, and what she did get down was vomited up. She could hardly procure any sleep. The pancreas was found scirrhous. Another woman, whose pancreas was scirrhous, had complained for seven years of a pain in her stomach, and of pains in her bowels, and hips ; a numbness of her thigh and leg with a sense of cold ; loss of appetite, and frequent acid vomitings.* CHAPTER XCVIII. Vertigo. A vertigo, giddiness, or swimming of the head, is a disorder in- cident to both sexes ; from which young persons, especially females, are not secure, though it be far more frequently found in the old and infirm. From a consideration of the cases, which I have had an opportu- nity of observing, it seems probable, that many vertigos have arisen from disorders of the stomach, more still from those of the head, but most of all from general weakness. If I were to judge from the ages, the constitutions, the juvantia and lsedentia, there is a very inconsi- derable number of vertiginous complaints, which can be attributed to a fulness of blood, and too high health; therefore in cases, in which there may be reason to suspect a plethora, we should proceed with caution, and feel out our way by observing how the first mode- rate evacuants were borne, and be guided accordingly in determin- ing the degree of strength, and the number of repetitions, which we may afterwards venture to use. Want of appetite, indigestion, flatulence, pain and weight in the stomach, sickness, vomiting, costiveness, and worms, have been found either to precede, or to be joined with a swimming of the head. Now, where some of these make either the only, or the prin- cipal complaints, next to the giddiness, we may reasonably conclude, that the head is affected only secondarily, and that the original seat of the disorder is in the stomach. * A man, twenty-three years of age, had been afflicted for five months with pains in the bowels, upon the ceasing of which the stomach swelled, and there came on indiges- tion, a diminution of the quantity of urine, and weakness, which gradually increased • lastly, a purging that could not be restrained. In the third month from the swelling of the stomach this man died. The pancreas was found enlarged to an enormous size and ulcerated.— E. VERTIGO. 193 Tormenting headaches, a lightness of the head, deafness, a singing in the ears, objects appearing double, temporary blindness, mists, black spots, or sparks and flashes of fire before the eyes, bleeding at the nose, hypochondriac and hysteric maladies, epileptic, paralytic, or apoplectic fits, lethargy, spasms, and convulsions (many of which are often united with vertigos), are all such manifest affections of the head, that where these predominate, the giddiness probably has its origin in the brain. Lastly, a vertigo has been accompanied with languor, tremblings, faintings, and palpitations, and has supervened inveterate gouts, ob- stinate intermittents, asthmas, and other long disorders, profuse bleed- ings, and diarrhoeas, and has often made one of the train of evils be- longing to a state of health much injured by the obstruction of some customary evacuation, as the menstrua, piles, sores, and cutaneous disorders, or utterly broken by intemperance, diseases, or old age, Nor is it unknown, that a vertigo should be the single complaint, the health being in all other respects unimpaired. Where there is satisfactory proof that the vertigo is dependent upon some other disorder, the most reasonable manner of endeavour- ing to cure it will be by removing the primary complaint. But it must be owned, that it is often difficult, from the strange complica- tion of symptoms, to decide what is the precise nature of the giddi- ness, or to account for the different events of remedies in circum- stances apparently the same. By the notes, which I have taken, it appears, that a spontaneous vomiting and diarrhoea have always been beneficial; that snuff, too much business and fatigue, a crowd, the first waking in the morning, stooping, standing, walking, turning in bed, and any alteration of posture, hot weather, a warm climate, fasting, and evacuations, have generally tended to bring on, or to aggravate a swimming of the head : that cupping, a discharge by the piles, bleeding by leeches, or by the lancet, blisters, cutaneous eruptions, emetics, issues, cold bathing, and the gout, have sometimes been judged to relieve a ver- tigo ; but that many of them have been far oftener useless, especially the gout, and blisters; but bleeding by the lancet, and strong ca- thartics have appeared to do harm much more frequently than good, and in most instances have at best been useless. If Bath waters have been innocent in this malady, they have never given me reason to think them beneficial. Cupping has often failed in relieving a pre- sent fit, but it has in several instances been singularly useful in pre- venting the returns, or in greatly mitigating their violence, by being used every two months, about six ounces of blood being taken away each time. The danger attending a vertigo, and the difficulty of relieving it, are to be estimated from its having no concomitant ails, or from their kind and number. Where it is accompanied with such as arise from the stomach, and especially if there be but a few of them, it is then more easily remedied, than when it is joined with affections of the head, the cure of which is tedious and uncertain. However, in hy- 25 194 HEBERDEN'S COMMENTARIES. pochondriac and hysteric casts, the danger of a vertigo is not much, though it may not be easily removed. But if the giddiness be only one of the many evils, of which an irreparably broken state of health consists, what hope can there be of a cure ? A vertigo unconnected with any symptoms of other diseases may probably be brought on by causes of too little importance to create any danger, or much disturbance to the general health ; for such a vertigo, though considerable enough in some young men to endanger their falling, has not hindered their outliving it, and arriving at a healthy old age; and several have been frequently troubled with it for twenty, or even thirty years, with good health in all other re- spects. CHAPTER XCIX. Vomitus* A disposition to vomiting is very various in different constitutions: some cannot be made to vomit by any means ; others not without ex- treme difficulty, and great pain; while several are prompted to it upon the slightest occasions, and it costs them not the least trouble. I have seen one who performed a sort of rumination : and if the food staid too long in his stomach, before it was returned back for this purpose, it became sour, and made him sick, and was vomited up. Vomiting seems so contrary to nature, that experience alone could satisfy us of the possibility of its being continued, as I have known it two or three times a day for many months, or many years, with little or no ill consequences to the health. One woman told me she had for thirty years vomited up all she had taken. In some cases, though all the food seemed to be vomited up, yet the patients have thriven, and grown fat. In pregnancy many women have judged that they brought up more than the whole of what had been swal- lowed, and that for a considerable time, without endangering the life either of the mother, or the child. In hard drinkers, and breeding women, the morning is the most usual time of vomiting; this has likewise happened, though rarely, in some sober men ; but in general it is either soon, or a few hours after eating, that the sickness comes on, which ends in throwing up the contents of the stomach. The stomach is secondarily affected by sympathizing, in a great many disorders, with other parts of the body; and it has many ails peculiar to itself, which hinder it from receiving, or retaining what has been swallowed : some of these are manifest after death, as scirrhous obstructions of the cardia, or pylorus : there are many others connected with the unknown powers of the stomach, which occasion no alteration of its appearance after death, as far as our senses are able to judge ; there being no more traces of them left, than of a nausea or vomiting excited by sudden ill news or the * Bee chup. lxv., concerning nuusea, or sickness of the stomach. V0MITUS. 195 sight or remembrance of disgustful objects. I remember one, who for many years had been subject to a vomiting of almost all his food, and often of great quantities of blood, whose stomach after death showed no signs of any disorder, though it was examined by some very experienced and skilful anatomists. The matter thrown up by vomiting has been sometimes the food unchanged, sometimes a salt or acid liquor, or phlegm, and by great straining a little bile will be pumped into the stomach, and thence brought up. A fat, inflammable matter, has often been forced up by mouthfuls not long after eating ; and lastly, blood, or a liquor deeply tinged with blood, has been vomited frequently, and in great abun- dance, for several days together, with extreme loss of strength; or else has returned, more like a chronical affection, in a slighter de- gree, two or three times a year for several years ; and though it have relieved a pain of the stomach, yet even this chronical sort must always be considered as the symptom of a dangerous disorder of this part. The apparent quantity of blood voided from the stomach upon these occasions is very alarming, and would be much more so, if it were not probable that blood itself makes often the least part of the bloody liquor which has been thrown up. Bloody, or black stools, have always accompanied a vomiting of blood. Some have had several returns of vomiting blood, and apparently in large quan- tities, for several years : and in others their first vomiting of blood has in two or three days ended in death. I know of no treatment required for this sort of hemorrhage different from what is men- tioned in the Medical Transactions, vol. ii., Query 4. The neces- sity of keeping the patient quiet, and calm, and cool, appeared very strongly in one case, where the least drop of wine, warming the hands at the fire, putting them into warm water, a warmed bed, a blister, a purge, and any ruffle or disturbance of mind, were often experienced to renew the bleeding. For other vomitings I have taken notice that purging, riding, and fat of every kind, have been prejudicial; that the spontaneous clear- ing of the stomach has given no relief; that an emetic has some- times failed, or even aggravated the complaint. I was told by one person, that he had the patience to persevere in the use of emetics, till he had taken near forty, without any success. However, an emetic has very generally proved serviceable : it seems better calcu- lated to relieve a sudden sickness, than to cure an old habitual vo- miting. Bath waters have been remarkably efficacious in curing the morning sickness of hard drinkers; but has failed in many other cases of sickness. The anodyne balsam rubbed in upon the sto- mach, has been very successful; and so likewise has a blister ap- plied to the region of the stomach. Acids have been useful to some of these patients, and the alkaline salts and testaceous powders to others. One person was cured by leaving off the use of bread ; and another by drinking water cooled* by ice. But it must happen that these and all other means will fail in stopping a sickness and vomit- ing, which arises, as it has often done, from incurable disorders of the stomach or neighbouring bowels. 196 HEBERDEN'S COMMENTARIES. CHAPTER C. Vox. The voice without any pain, or other disorder of the health, has been weakened so as never to rise above a whisper. In a slight de- gree of this complaint the persons are able to laugh in the usual manner ; but they are sometimes as incapable of laughing, as of speaking, loud. Those who have once experienced such a failure of voice have been very subject to relapses. They have lost their voices suddenly without any previous notice, and recovered them as quickly without any apparent cause. Nine out of ten of those, whom I have seen in this complaint, have been women, and most of them, but not all, have been young and puny, or hysteric, or old and infirm. An inability to speak beyond a weak whisper has frequently lasted for many months, and in some for several years in the sam» uniform manner. Others have lost their voices only for the morning, or after- noon, of every day; or for a certain number of months in every year. Sea bathing, and blisters, have been supposed to do some little service. Internal stimulants, and evacuants, have hardly been innocent; they have certainly been useless, and so have all other means which I have tried. The sudden weakness of voice, of which I have been speaking, is very different from that hoarseness, which belongs to bad cough, asthmas, and catarrhs. CHAPTER CI. Urina* An eager desire of making water has been considered under the article of Stranguria, and Prostatas Scirrhus, and Calculus. Beside the causes there mentioned, it has been an attendant upon a scir- rhous spleen, and upon hysteric and paralytic maladies, and has been one of the infirmities of old age, where there has been no other dis- temper. It has been very troublesome to several in the night, so as greatly to interrupt their rest; and it has teased others only in the day-time, suffering them to rest quietly in the night. A difficulty of expelling the urine has not only arisen from the causes mentioned under Stranguria, and Ischuria, but also from a paralytic inability of the muscles which should expel it. In one man the catheter was necessary for this purpose during the space of two years, after which the parts recovered their use, and the incon- venience ceased. The colour of the urine has been milky in a diseased prostate gland, and in other cases, where it might be owing to some puru- lent liquor with which it was mixed. A large suppuration of an inflamed sore throat has been attended * See Calculus, Graviditas, Ischuria, and Stranguria. URINA. 197 with a considerable quantity of pus at the bottom of the vessel which held the urine, for three or four days. As soon as the abscess broke and discharged itself, this purulent appearance in the urine ceased. This is the only instance that has occurred to me of any thing like a translation of matter from other parts to the kidneys. In some broken constitutions, whenever water was made, there has followed a great languor, or sickness of the stomach. An ulcer of the womb has in several women pierced the rectum and the bladder, so that wind and feces would come away with their urine. An ulcer, probably of the prostate gland, has had the same effect in men: and one person believed that the breach between the bladder and rectum had been the consequence of efforts occasioned by excessive costiveness. A stone in the bladder, a diseased prostate, the fluor albus, fre- quent miscarriages, and some rough or pungent liquors, have occa- sioned a heat of urine, where there was no reason to suspect a vene- real cause. The bladder is naturally defended from the sharpness of the urine by a mucous substance with which it is lined. All irritation, from whatever cause it may arise, increases this glairy matter, which will adhere to the vessel into which it is made, like starch. It is very different from true pus, which settles at the bottom of the urine like cream ; both these appearances have been found to arise from irri- tation joined with some inflammation, without any ulcer: there will at the same time be more or less eagerness to make water, and pain in making it, according to the degree and cause of the irritation. A diseased prostate gland, inflammations or ulcers of any of the urinary passages, strictures of the urethra, frequent venereal injuries, and the stone, or gravel, have been the common sources of these appear- ances in the urine. If the purulent liquor be considerable in quan- tity, mixed with streaks of blood, and fetid, while the neck of the bladder is in a natural state, it may probably be conjectured that there is an ulcer of the kidney, but of this it is hard to form a certain judgment. An incontinence of urine, though void of danger, is yet an ex- tremely inconvenient and distressing infirmity. Youth and old age are peculiarly liable to it. In some weakly boys it has continued from their infancy almost to the age of puberty ; but much longer in girls, and in many more of them, and such who seemed in all other respects healthy. Females in general are more apt to have their urine pass away ; so that laughing, or coughing, will more frequently force some of it from them, than from men ; and some women, without any ill health, have all their lives had no power to retain their water. It is therefore a less alarming symptom in dangerous illnesses of women, than of men. Among the morbid causes of in- continence of urine may be reckoned all disorders of the urinary passages, the cutting for the stone, or the extraction of it by dilating the urethra, difficult labours, a prolapsus vaginas, venereal injuries, epileptic and paralytic affections, and whatever else can bring on extreme weakness in general, or of the urinary parts in particular. 198 HEBERDEN'S COMMENTARIES. A decoction of the Peruvian bark, and cold bathing, may be of some use in restoring more expeditiously the general strength after any illness, and so far contribute to remedy this infirmity; a blister may also be applied just above the os sacrum, in order to stimulate more particularly the parts concerned in retaining the urine. Where these have no effect, either time alone must cure the complaint, or it must be considered as incurable ; in which case, for the use of males, a yoke has been contrived, which by means of a screw, compresses the urethra, and hinders the dripping of the water. I have known several try this contrivance, but they found it so inconvenient, that they soon laid it aside. Some in its room have substituted a bladder, in which the penis was constantly kept in the day-time : this may be less cumbersome, but is not so neat as a tin vessel, which others have used for the same purpose. The most effectual way of keeping the bed dry, is to put the penis and scrotum into a small chamber- pot, and to keep them in this situation all night. A little practice has made this method easy to several persons, who have preferred it to all others. Urine made of a deep coffee colour, or manifestly mixed with a large quantity of blood, has within my experience very rarely been the effect of any thing but a stone in the urinary passages. I there- fore suppose a strong probability of this cause, wherever I see this appearance; and if there be joined with it any of the usual symp- toms of the stone, I have no further doubts. A very painful stran- gury from the internal or external use of cantharides, has seldom, if ever, gone beyond making a slight redness of the water, with some few streaks of blood in the mucus. A scirrhous prostate gland, when it becomes ulcerated, has occa- sioned some blood in the urine; but the quantity is very small, and is not increased by riding or walking ; and whenever this is the cause, a surgeon by examining can hardly fail to discover it by the swelling and hardness. Cancerous sores communicating with any part of the urinary passages, may tinge the urine with blood ; but these too may be conjectured from the constancy of the pains, from the small quan- tity of blood, from its not being remarkably increased upon motion, from the fetid mucus, or sanies, which issues from them, as well as from their wanting several peculiar signs of the presence of a stone. A blow upon the loins has appeared to occasion bloody urine ; and I suppose a blood-vessel may happen to burst in the kidneys, or bladder, not only from such a violent cause, but from as slight an one as it often does in the nose; though I do not remember such an in- stance. But I have once or twice known a very profuse bleeding into the urethra from some of the neighbouring vessels, without any pre- vious distemper, or extraordinary injury of the part: the blood kept constantly running out without any effort to make water, and without its being in the person's power to check it. In one of these cases the bleeding returned frequently for two years, during which time the health was gradually impaired, and at the end of the second year the patient died ; the grumes of blood were often voided with diffi- culty, and occasioned great distress. 1 TERUS. 199 In the worst kinds of small-pox the blood is well known to pour out from the urinary passages, as well as from other parts, in great abundance. Many other causes of bloody urine are to be found in medical writers, which, if they exist, have never occurred in my practice. Quiet, and keeping the body cool, and open, are all the means of relief, with which I am acquainted. CHAPTER CII. Uterus. A prolapsus of the vagina or the womb is only to be relieved by a pessary : it is apt to be attended with an incontinence of urine. Several women have experienced a sudden and great discharge of water from their wombs; this has happened to the same women more than once, and about the time of the menstrua taking their final leave. No ill consequences have followed this appearance, besides weakness. There has grown out from the womb a fleshy substance like a pear, the body of it being much larger than the stalk. This has extended itself so as to be perceivable in the vagina in straining upon> going to stool. The great evil arising from this, is a constant discharge of blood from the dilated parts, which discharge will necessarily con- tinue till the excrescence be removed. An experienced accoucheur assured me that he had taken away near twenty of these by passing a ligature as near as possible to the part adhering to the womb : in a few days after this has been done, the mass falls off, and the re- maining stalk putrefies away, requiring nothing but frequent injections of an infusion of camomile flowers. He told me this operation had been generally successful, and it has proved so, where I have known it performed. The furor uterinus does not always arise from a preternatural state of the womb, but, sometimes at least, differs not from common mad- ness ; the mind, no longer under the guidance of reason, is made a prey to such thoughts as work it up to the oestrum venereum, instead of those which might inflame it with religious zeal, ambition, or a desire of revenge. I have seen it not only in the young and middle- aged, but in a dying old woman, who had long been in a broken state'of health, from which circumstances, as well as from the de- cency of her character, it may be judged that all delight in the ob- jects upon which she raved, had been long passed and forgotten. Besides, it happens sometimes to the other sex, that madness lets loose the passion of lust, as well as those of fear, or anger. The womb, as well as the breasts of women, is subject to scirrhous tumours, which slowly turn to incurable ulcers. This happens at the same time of life, with similar disorders of the breasts, that is, gene- rally after the age of forty. The first symptom is often a return of the menstrual discharge after it had long ceased : but this is no cer- 200 HEBERDEN'S COMMENTARIES. tain sign ; for its re-appearance has sometimes proceeded from other causes,* as well as from a scirrhous state of the womb. In some women the first alarm is given by a copious discharge of a tenacious mucus like jelly, or of a thinner fluid, like the fluor albus : this has continued for one or two years, intermixed now and then with a dis- charge of blood, before any of the more violent symptoms have come on. These are, pains of the womb, in the groin, in the loins, in one or both of the hips, and in the thighs ; pains in going to stool, and in making water, with a tenesmus, and a frequent call to make water, a manifest fulness of the abdomen, and, at the same time, a sense of emptiness, and a hectic fever. The discharge afterwards becomes yellow, green, or black, and fetid ; and the pains are so excessive, as hardly to be endured without benumbing the sense of them in some degree by large quantities of opium. They are scarcely increased by the motion of a carriage. In a few cases the ulcer of the womb has eaten a passage to the bladder, and to the rectum. All these symp- toms do not happen in every case ; but a very few of them are sufficient to show the nature of the disease, even before it has been ascertained by a midwife's examination of the womb. The extract of hemlock washed down with a decoction of the Peru- vian bark is at least innocent in this disorder ; but I have had very little reason to judge this, or any other medicine, to be of much avail in curing, or checking the progress of the cancer. One woman was very remarkably relieved, while she was taking the extract, and at the same time using an injection of the decoction of hemlock; the pains almost vanished, and the womb remained in such a quiet state for some years, as to give very little interruption to her usual amuse- ments, or manner of living. But in most other cases no good could be done, but by administering in a proper manner some preparation of opium. THE CONCLUSION. It might be expected, that the experience of fifty years spent in the practice of Physic, would have taught me more, than I here appear to have learned, of distempers, and their remedies. I readily confess my knowledge of them to be slight and imperfect; and that a considerable share of this imperfection is chargeable upon my want of ability to make a better use of the opportunities I have had : but at the same time it must be allowed, that some part must be put down to the very great difficulty of making improvements in the medical art. This is too evident from the slow progress which has been made, though men well qualified by their learning, experience, and abilities, have for above two thousand years been communi- cating to the world all they could add by just reasoning to the facts * See Chapter lxii. APPENDIX. 201 collected by attentive observation. Whoever applies himself to the study of nature, must own we are yet greatly in the dark in regard even to brute matter, and that we know but little of the properties and powers of the inanimate creation: but we have all this dark- ness to perplex us in studying animated nature, and a great deal more arising from the unknown peculiarities of life : for to living bodies belong many additional powers, the operations of which can never be accounted for by the laws of lifeless matter. The art of healing therefore has scarcely hitherto had any guide but the slow one of experience,* and has yet made no illustrious advances by the help of reason; nor will it probably make any, till Providence think fit to bless mankind by sending into the world some supe- rior genius capable of contemplating the animated world with the sagacity shown by Newton in the inanimate, and of discovering that great principle of life, upon which its existence depends, and by which all its functions are governed and directed. appendix; CONTAINING 1. A Sketch of a Preface designed for the Medical Transactions, 1767. 2. Observations on the Chronical Rheumatism. 3. On the Pulse. 4. On opening a Vein in Hemorrhages. . A Sketch of a Preface designed for the Medical Transactions, 1767. The world has had more than sufficient experience how far either building upon the ancients, or upon reasonings a priori, is likely to improve" us in natural knowledge. By laying aside both these me- thods, and by attentively observing nature itseIf, a greater progress has been made during the last century, than had been till that time from the days of Aristotle. . , The manner in which these observations have been communicated to the world, appears to have had no small share in the advantages which have been gained. The several learned societies in Europe, which have joined in forming one common stock of knowledge, have received contributions from many, who would otherwise never have • Vntt»t C,*TgOC .f.T„6.IC T» W*„*X..,T.,6 « .«,*«,«■, T„8« T„ *{.,., *,. Stol.fi /.'. >«g. I'hys., lib. i , page 19. 26 202 HEBERDEN'S COMMENTARIES. published the remarkable phenomena which chance had thrown in their way. They have likewise hindered many from overlaying their little original knowledge, by compilations from others, or by crude reasonings of their own, which they might think necessary to furnish out a just volume. Thus they have had the good effects of inviting some to tell all that they knew, and have lessened the temptation which others might have, to say more than they knew. It is a misfortune to the world, that the several societies of phy- sicians in Europe have not more generally adopted the same plan ; as there can be no question made of its being attended with as much success in their particular study, as it has been in that of every other part of nature. It is high time that this should be done, as physi- cians have, like other natural philosophers, fully run the round of com- menting the ancients, and contriving theories, and teaching system- atical doctrines in many a celebrated school; and just with the same success. The deference, which is sometimes required in physic to the autho- rity of the ancients, would incline any one to suspect, that the improve- ments in the art of healing had not kept pace with those which have been made in other branches of natural knowledge. Philoso- phers have long ago thrown off Aristotle's tyranny ; yet some physi- cians still choose to wrangle about the meaning of the ancients, rather than to consult nature herself. Are they afraid of approaching her immediate presence, without making use of the intercession of Hip- pocrates and Galen ? and is that reverence to be still paid to her once faithful ministers, which is properly due to nature alone ; notwith- standing all that Bacon, and Harvey, and Newton, and our other great reformers, have witnessed against this mistaken veneration ? In works of genius the ancients are unqestionably our superiors, and best patterns ; but in that sort of knowledge which depends wholly upon experience, the latest writers must in general be the best. But this disagreeable and unpopular topic needs be pursued no farther; not only because every scholar must be loth to say, or hear, any thing against the ancients ; but because they are in reality very little read and attended to by practitioners, though the fashion of quoting and recommending them be still prevalent in some modern writers. It has been an old dispute among physicians, whether the empirical, or rational method of curing diseases was to be preferred. If by the empirical method be meant that which is founded on facts recorded by others, or observed by ourselves, it must be allowed, that by this means only has the practice of physic been established. Fact, and repeated experiments, have alone informed us that jalap will purge, and ipecacuanha vomit, that the poppy occasions sleep, that the bark will cure an ague, and that quicksilver will salivate. If we examine the whole materia medica, and the whole practice of physic, we shall not find one efficacious simple, nor one established method of cure, which were discovered, or ascertained, by any other means. Experience may, in politics and morality, be called the teacher of fools j but in the study of nature there is no other guide to true APPENDIX. 203 knowledge: accordingly the practice of physic has been more im- proved by the casual experiments of illiterate nations, and the rash ones of vagabond quacks, than by the reasonings of all the once cele- brated professors of it, and theoretic teachers in the several schools of Europe: very few of whom have furnished us with one new me- dicine, or have taught us better to use our old ones, or have in any one instance at all improved the art of curing diseases. Hence, though they have been applauded during the lives of their disciples, yet disinterested and impartial posterity has suffered each succeeding master of this sort to be gathered to his once equally famous prede- cessors, and to be, like them, in his turn utterly unread and forgotten. It is necessary to be upon our guard even against experience itself, when delivered in a system ; the very notion of which seems to im- ply, that the facts and observations are not barely related, but are ranged into some method, and formed into one body dependent upon what the compiler takes to be their general cause or nature ; and hence arises the great danger of their being misrepresented in order to make them fit more exactly the several places which are assigned them. The Jews were commanded to build their altar with stones unhewn and untouched by any tool ; and, in like manner, the best materials of natural knowledge are the plain facts themselves, just as they come from nature ; he who pretends to new model and polish them, in order to their being adapted more perfectly to his system, has utterly polluted them, and made them unfit for the altar of truth. Nor let any one apprehend, that physic will become too easy a study, by making it thus wholly depend upon experience; and that, by losing the fence of learned theories, it will be an easy prey, open to the invasions of every ignorant pretender. For, whatever weight there may be in this objection, it will be found to be greatest against the way of theory and hypothesis ; this being much the cheapest, and most expeditious method of making a physician. A heated ima- gination will always supply us with knowledge, such as it is, much faster than the ordinary course of nature. The road of experience is tedious, and requires great judgment as well as patience. The contrary to this seems, indeed, to be the general persuasion: for every one is apt to fancy himself a competent judge of medical ex- perience, and is ready to trust any one else who pretends to it. But, to form a right judgment, a man must be trained to a habit of think- ing attentively by a learned education, and should not only be ac- quainted with the nature of the materia medica, but also with the several hypotheses, with the false philosophy, the mistakes in lan- guage, and other sources of error, upon which the supposed virtues of remedies have been, and are still often founded. And after all, it will be found extremely difficult, to determine rightly upon the intri- cate and contradictory evidence which is frequently brought for the effects of medicines. The Peruvian bark was known and tried in Europe, at least forty years before its virtues and dose could be properly ascertained. The solvent power of medicines for the stone of the bladder, is what lies 204 HEBERDEN'S COMMENTARIES. much more obvious to the senses, than the efficacy of most other medi- cines ; and yet, in the late instance of Mrs. Stephens's remedy, how difficult a thing was it found to determine this, though tried in a va- riety of cases, which were diligently attended by the ablest judges ? No wonder, therefore, that out of the innumerable cathohcons, or universal medicines, with which every nation and age has swarmed for these last thousand years, not one has survived ; and out of as great an inundation of specifics, or remedies for particular diseases, which have readily found patrons* sufficient to give them a fair trial, the bark and quicksilver are almost the only two, which have stood the test of time and general experience. As therefore the art of healing owes so little to any other teachers, and so much to experience, the College of Physicians in London is desirous of collecting the experience of its members, and their cor- respondents, in the manner which has answered so well in the Royal Society here, and in many other literary associations abroad, and is therefore ready to receive medical papers in order to communicate such as are approved to the public. For want of such an opportunity of communicating their know- ledge, it has often happened, that many judicious practitioners have carried the whole experience of forty years, spent in an extensive practice, with them to the grave, much of which would, probably, by the means now proposed, have been preserved, and might have been as useful to posterity, as it had been to their contemporaries. Medical papers are, indeed, received into our own Philosophical Transactions, as well as into the journals and memoirs of many other learned societies ; but it is apprehended, that if a society of physicians professed to receive such papers, and communicate them to the public, there would be many more communicated, and per- haps, with better choice, and they would more certainly come into the hands of physicians, without being lost in the crowd of other papers. If the present intentions of the College are seconded, as there is reason to hope they will be, they may excite in every practitioner belonging to it, a more constant attention to all the circumstances of remarkable and instructive occurrences; they may strengthen the habit of noting, and of recollecting, and of forming conclusions from what passes before him, and prove the means of preserving some observations, which would otherwise be lost, not only to the public, but to the observer himself. Though the principal view of the College be to perfect the history of diseases, and to ascertain the effects of medicines, yet any other papers will be received, which in any manner relate to medical subjects. Many, who have communicated their observations to the world, have purposely picked out such as were rare and extraordinary, such as have seldom happened before, and may never happen again. * Uomrnuni enim fit vitio nature, ut invisis.Iatitantibus (al. intentatis), atque incog- nit ';■> rebus magis confidamus. Cresar dc BelL Civ. lib. ii., c. iv. APPENDIX. 205 Now, though these may be worth preserving, for almost all facts teach something, yet surely the preference ought not to be given to such as these, unless the chief end of our writing be to amuse the reader by gratifying his curiosity. If a man have only leisure to give either his unusual cases and cures, or such as may frequently occur in every day's practice, it would be more for the reader's use, if not for the writer's credit, to draw up only the latter, and leave, according to the proverb, e«U/u*T* ,u»go«. It were also to be wished, that writers would not confine them- selves to relate only their successful practice, but that they would have the courage to tell us the ineffectual and hurtful. It is some- times almost as useful to know the lsedentia (especially if they are likely to throw themselves in our way, if not carefully avoided) as the juvantia ; and any physician of great experience might make a very useful paper, by giving an account only of such medicines and methods of cure, which he had found to be useless and incon- venient. Single cases of the catalepsy, hydrophobia, and other rare distem- pers, may be worth the relating; but histories of particular cases, where the distemper is a common one, and of such effects of medi- cines as occur every day, must be endless, and would rather tire and oppress, than instruct the reader. Whatever important additions, or exceptions to the common practice, are contained in such cases, would much better be drawn out by the author, who can best do it, and presented by themselves, without giving along with them a tire- some history of common appearances, which every one had often seen, and was well acquainted with long before. There may be some, but it is hoped there will not be much occa- sion for bespeaking the reader's candour, if some papers thus pub- lished by the College should appear less deserving of his notice. In so small a society, where the members are all personally known to one another, something must be expected to be given to civility ; as an author, who is usually not the best judge of his own works, may now and then have a fondness for some paper beyond its merit; and the College may determine more out of regard to the writer, than to the piece. But this, we trust, will not often happen, nor in any fla- grant instances; and little matters, which may be imputed to this cause, the considerate reader will easily overlook, as without some indulgence of this kind, the design could hardly be carried on, and consequently, the papers of more importance would be lost. 2. Of the Chronical Rheumatism. The disease called the chronical rheumatism, which often passes under the general name of rheumatism, and is sometimes supposed to be the gout, is in reality a very different distemper from the ge- nuine gout, and from the acute rheumatism, and ought to be care- fully distinguished from them both. It is attended with little or no fever, and most commonly with no very great pain ; and in both these respects it differs from the acute 206 HEBERDEN'S COMMENTARIES. rheumatism. The swellings are in most instances, though not in all, very great, but have hardly any redness ; they are not particularly apt to begin in the foot, or if they do, they soon leave it, and pass on to other parts of the limbs, several of which, one after another, be- come the seat of the distemper in the very first fit. The true arthri- tic pains are different in all these circumstances, if we except the swelling, as well as in their intensity. An attention to these particu- lars will enable us in the very first week of the fit to form a judg- ment of its nature, and will show us to which of these three it be- longs. Afterwards this will be further evinced by the extreme weakness it occasions in the limbs, and the severe shock which it gives to the constitution and general health, patients being often more disabled by a single attack of the chronical rheumatism, than they are by annual returns of the true gout for many years. Arthritic patients seem peculiarly liable to the palsy, and apoplexy, beside having the use of their limbs destroyed in consequence of frequent inflammations of the joints, or contractions of the muscles: but all this mischief is in these patients the work of a long time, and to many of them it happens either not at all, or but in a slight de- gree ; while the first fit of the chronical rheumatism, if it be continued, as it often has been, for several months, will do irreparable injury to the limbs, bringing on a state of almost paralytic weakness, and greatly impairing their use during the whole life. A frequent repe- tition of the disease has in six years totally taken away the use of all the limbs; and in some very bad cases this has happened even in the first year. Nor is this rheumatism less strongly marked by the continuance of the first fit, from which few are so fortunate as to be released under three or four months ; while the first fit of the true gout seldom lasts twenty days. It is much more apt to return than the acute species, under which many have laboured once, without ever experiencing it a second time. But though the chronical rheumatism most usually repeats its visits, yet their intervals are far more unequal than those of the gout. It may in some cases come on regularly once a year, for a few years; but others suffer two or three returns within the same year ; and some patients have been hardly ever free for several years; while others again have had intermissions for five, or six or even for near twenty years. Cramps are very common in this disorder, as well as in the gout The swellings, which it occasions, are often remarkably great and some degree of them will continue for many years, or for the patient's life, particularly in the wrists, and sometimes in the fingers and ankles. The pains are not subject, like those of the acute so'rt to be increased, but are rather relieved by the warmth of a bed ' I have observed very few instances where the contrary to this has happened. The stomach and bowels are much oftener, and more readily affected in this rheumatism, than in the true gout. Pain nausea and universal languor, are its ordinary effects in these parts' Upon APPENDIX. 207 the application of a warm plaster, or liniment, to the affected limb, the distemper has presently been thrown upon the bowels; and in some instances, pains have seized the limbs and stomach alternately. Sometimes the anguish of the abdominal viscera, and the weakness of the extremities, makes this disease bear no little resemblance to the colic of Poitou ; and they both bring on a rapid decline of the ge- neral health. The distemper of which I am speaking, seems confined to no sex, and hardly to any age. The rich and the poor are equally liable to it. It has happened to me to see rather more women than men afflicted with it. In some it has begun at the age of twelve years ; in others not till they were past sixty. Is it not in some degree he- reditary ? The chronical rheumatism for a few days appears to be a milder distemper than either the acute sort, or the gout: but in its conse- quences, that is, in the great weakness, or total loss of power it pro- duces in the limbs, and in the mischief done to the general state of the body, it is much more formidable than either of them ; and being so very different in its symptoms, as well as in the event, it would be useful if it were distinguished by a peculiar name, which might prevent its being confounded with other disorders, by being called a spurious and wandering gout, or a chronical rheumatism. The waters of Bath and Buxton, preparations of antimony and of quicksilver, sea-bathing, cold and warm bathing, blisters, and warm liniments, have in some of these patients been thought serviceable ; but all these, together with bleeding, purging, sweating, and electri- fication, have been of no use to others; some have even thought them hurtful. A course of mercurial medicines has with great reason been suspected of bringing on something like this distemper in many per- sons ; and it has appeared to do so in the same person five or six times, that is, as often as the mercury was repeated. It is not surprising, if against a disease which has been so imper- fectly discriminated, as the chronical rheumatism, no certain method of cure should have been discovered. Wherever that is the case, the physician will fully discharge his duty by attending to the trou- blesome symptoms, which it is often in his power to relieve, to the great ease and comfort of the sick, and by assisting nature in bring- ing all the functions of life as near as may be to their natural state in health. A prudent use of opium will be one of the means of ob- taining these very desirable ends ; and much good may also be done by supporting the appetite and digestion with Peruvian bark, and bitters, and other stomachic medicines; the class of which appears to have some specific power not only in this distemper, but likewise in the gout. 3. Remarks on the Pulse. Read at the College of Fhysicians, July 7th, 1768. All, who begin the study of physic, must find in the doctrine of 208 HEBERDEN'S COMMENTARIES. the pulse, as collected from medical writers by Bellini and others, a great deal which they do not understand; and all, I imagine, who have advanced a little in the practice of physic, can have very little doubt of its not being understood by the authors themselves. Such minute distinctions of the several pulses, if they do not exist chiefly in the imagination, 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 it may be doubted, whether some of those, which are retained, are perfectly understood, or applied by all to the same sensations, and have in every one's mind the same mean- ing. I have more than once observed old and eminent practitioners make such different judgments of hard, and full, and weak, and small pulses, that I was sure they did not call the same sensations by the same names. It is to be wished, therefore, that physicians in their doctrine of pulses, and descriptions of cases, had attended more to such circum- stances of the pulse, in which they could neither mistake, nor be mis- understood. Fortunately there is one of this sort, which not only on this account, but likewise for its importance, deserves all our attention. What I mean is, the frequency or quickness of the pulse, which, though distinguished by some writers, I shall use as synony- mous terms. This is generally the same in all parts of the body, and cannot be affected by the constitutional firmness or flaccidity, small- ness or largeness of the artery, or by its lying deeper or more superfi- cially ; and is capable of being numbered, and consequently of being most perfectly described and communicated to others. The degrees of quickness of the pulse belonging to the several ages and distempers, have been taken notice of by few physicians in their writings; and as many observations are necessary to settle this doctrine, what I have made and am going to relate, may be of use towards confirming, correcting, or enlarging those which have been made by others. When the nnmber of pulsations is mentioned without any time being specified, a minute is to be understood. The pulse of children under two years old should be felt when they are asleep ; for their pulses are greatly quickened by every new sen- sation, and the occasions of these are perpetually happening to them while they are awake. The pulse then of a healthy infant asleep on the day of its birth, is between 130 and 140 in one minute ; and the mean rate for the first month is 120 ; for during this time, the artery often beats as frequently as it does the first day, and I have never found it beat slower than 108. During the first year the limits may be fixed at 108 and 120. For the second year at 90 and 108. For the third year at 80 and 100. The same will very nearly serve for the fourth, fifth, and sixth years. In the seventh year the pulsations will be sometimes so few as 72, though generally more : and, in the twelfth year in healthy children they will often be not more than 70; and therefore, except only that they are much more easily quickened by illness, or any other cause, they will differ but little from the healthy pulse of an adult, the range of which is from a little below 60 to APPENDIX. 209 a little above 80. It must be remembered, that the pulse becomes more frequent, by ten or twelve in a minute, after a full meal. If the pulse either of a child, or an adult, be quickened so as to exceed the utmost healthy limit by ten in a minute, it is an indica- tion of some little disorder. But a child is so irritable, that during the first year, a very slight fever will make the artery beat 140 times, and it may beat even 160 without danger; and as there begins to be some difficulty in counting the pulse when the motion is so rapid, the thirst, quickness of breathing, averseness from food, and above all, the want of sleep, enable us, better than the pulse, to judge of the degree of fever in infants. A child of two years may die of an inflammatory fever, though the artery beat only 144 times in a minute ; and I have seen a child of four years recover from a fever, in which it beat 156 times ; and one of nine, where it beat 152. If the pulse of a child be 15 or 20 below the lowest limit of the natural standard, and there be, at the same time, signs of considerable illness, it is a certain indication, that the brain is affected, and con- sequently such a quiet pulse, instead of giving us hope, should alarm us with the probability of imminent danger. In adults ill of an inflammatory fever the danger is generally not very great, where the beats are fewer than 100; 120 show the beginning of danger ; and they seldom exceed this number unattend- ed with deliriousness, and where the patient does not die. There are two exceptions to this observation : the first is, that before some cri- tical swelling or deposit of matter begins to show itself in fevers, the pulse will be so rapid and indistinct, as hardly to admit of being counted ; but I have known it certainly not less than 150, and yet the patient has recovered. Acute rheumatisms afford a second ex- ception ; in which the artery will often beat above 120 times without any sort of danger; and in both these cases we may remark, that the appetite and senses, and sleep, and strength, are put less out of their natural state, than where the life of the patient is in imminent danger. Though it be difficult to count above 140 strokes in a minute, if if they be unequal in time or in strength, yet where they have been very distinct, I have been able to count 180. Asthmatic persons are often seized with an uncommonly bad fit, arising probably from some great inflammation of the lungs ; and here, if the pulse exceed 120, they very rarely recover. In an illness where the pulse all at once becomes quiet from being feverishly quick, while all the other bad signs are aggravated, it is a proof, not of the decrease of the disorder, but of the lessened irrita- bleness of the patient, the disease being translated to the brain ; and a palsy, apoplexy, or death, is to be apprehended. In low fevers, and in exhausted old men, the pulse will often con- tinue below 100, or even 90, and yet the distemper be attended with want of sleep, deliriousness, restlessness, and a parched tongue, and end in death, without any comatous or lethargic appearances. Scirrhous disorders of any of the \i:-ceui in an inflamed state, can- 27 210 HEBERDEN'S COMMENTARIES. cms, and gangrenous or otherwise ill-conditioned large ulcers, usually occasion a gradual loss of flesh, a heat, thirst, and a pulse between 90 and 120 for many months. This state of the body is called a hectic fever ; and some judgment may be formed of the degree of danger by the frequency of the pulse. But a quickened pulse more certainly denotes danger, than a natural one does security, where there are ulcers, or where disorders of the viscera are suspected. I have known persons die of cancerous ulcers of the anus, testicles, prostate gland, and of almost all the viscera, without ever showing any preternatural quickness of the pulse. It is observable in hectic, as well as in rheumatic patients, that they will eat with a tolerable appetite for many months, and bear little journeys, with such a quick- ness of pulse, as in acute fevers would be joined with an averseness from all food, and an inability to keep out of bed. From these remarks it appears, that the pulse, though in many cases an useful index of the state of the health, yet is no certain one in all; and that, without a due regard to other signs, it may mislead us: a good pulse (which I have known in comatous fevers) with deliriousness, rapid loss of appetite, and strength, sleeplessness, quick- ness of breathing, and great thirst, would afford very little hope ; and a bad one without any of these might be harmless. I remember two young women ill together with others in the same house, of the same infectious fever ; the pulse of one of which was never above 84, and the pulse of the other was always extremely quick, and I once counted it, when I thought her dying, 180. Both of them recovered, and the latter quite beyond my expectation; for, except in this instance, I hardly remember any one recover from such a fever, where the pulse exceeded 120. But the first of these was stupid, insensible of the coming away of her water or stools, and per- haps her brain was affected comatously, which might make her pulse so slow. The pulses of women will sometimes exceed what I have men- tioned as the highest limit of the healthy standard, and sometimes, though more rarely, those of men ; but the pulses of men afford more exceptions in falling short of the lowest. There are very few healthy men, whose pulses are more than 90 ; and I knew one, 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 42 pulsations; but they were seldom above 30, and sometimes not more than 26 ; and though he seemed heavy and torpid, yet he could go out in a carriage, and walk about his garden, receive company, and eat with a tolerable appetite. I saw another, whose pulse, as I was told, was sometimes in the beginning of his illness not above 12 or 16 in a minute ; but in this, and all other instances where it is below 40,1 suspect 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. APPENDIX 211 Some books speak of intermitting pulses as dangerous signs, but, I think, without reason ; for such trivial causes will occasion them, that they are not worth regarding in any illness, unless joined with other bad signs of more moment. They are not uncommon in health, and are often perceived by a peculiar feel at the heart by the persons themselves every time the pulse intermits. A woman above fifty years of age, who died of a cancer of the womb, had from her youth frequently experienced this sort of intermittent pulse; and that the cause of this intermission might be discovered, she was opened after her death, as she had desired she might be. It was done by a very experienced and able anatomist; but he could discover not the least appearance of any thing preternatural in the pericardium, or heart, or any of the great vessels belonging to it; so that, for aught that appeared to the contrary, she might, notwithstanding this complaint, have died of old age. Many persons will likewise have unequal pulses without any other sign of ill health. I have met with two, who in their best health always had pulses very unequal both in their strength and the spaces between them ; upon their growing ill, their pulses constantly became regular ; and it was a never-failing sign of their recovery, when their arteries began again to beat in their usual irregular manner. It is often supposed that great pain will quicken the pulse : I am more sure that mere pain will not always do it, than I am that it ever will. The violent pain occasioned by a stone passing from the kid- neys to the bladder, is often unattended with any quickness of the pulse ; and the excessive and almost intolerable torture produced by a gall-stone passing through the gall-ducts, has in no instance quick- ened the pulse beyond its natural pace, as far as I have observed, though it be a disorder which occurs so very frequently: and this natural state of the pulse, joined with the vehement pain about the pit of the stomach, affords the most certain diagnostic of this illness. I have seen a man of patience and courage rolling upon the floor and crying out through the violence of this pain, which I was hardly able to lull into a tolerable state with nine grains of opium given within twenty-four hours, to which he had never been accustomed, and yet his pulse was all the time as perfectly quiet and natural, as it could have been in the sweetest sleep of perfect health. 4. On Opening a Vein in Hemorrhages. Read at the College of Physicians, December 11, 1771. It has been the practice of physicians to take away blood from the arm or foot, in order to stop violent hemorrhages from some other parts, which do not admit of a topical application. If it be intended by this practice to weaken the power of the heart, and to "ive the lips or ends of the broken blood-vessel a chance of collapsing, or of being plugged up by means of a more languid cir- culation,Would not all this be as likely to happen after the patient had been equally weakened by losing the same quantity of blood 212 HEBERDEN'S COMMENTARIES. from the original rupture ? And in the meantime he might stand a chance of its stopping spontaneously, before he was reduced to that degree of weakness. It seems probable, from all the experience which I have had of such cases, that where the hemorrhage proceeds from the breach of some very large vein, or artery, there the opening of a vein will not stop the efflux of blood ; and it will stop without the help of the lancet, when it proceeds from a small one : in the former case, bleed- ing does no good ; and in the latter, by an unnecessary waste of the patient's strength, it will do harm. But if the opening of a vein be intended to stop an hemorrhage by deprivation or revulsion, may it not be questioned, whether this doctrine be so clearly established, as to remove all fears of hurting a person, who has already lost too much blood, by a practice attended with the certain loss of more? The best remedies seem to be a cool air ; quiet; a very sparing mild nourishment, administered in small quantities at a time ; drinks acidulated with any acids; opiates in small doses (for any strong perturbation of mind will often occasion a return of the bleeding); and lastly, keeping the body moderately open. A very experienced physician told me, that, by the help of gently purging with some of the salts, he had done more good in excessive losses of blood from the nose, than by any other means. I do not lay any great stress upon the use of internal astringent remedies, because it does not appear likely from reasoning that they should do any service ; and I am far from being convinced by experience, that they ever do, ex- cept perhaps in hemorrhages of the primse viae. They may some- times have appeared to be attended with success, because there is hut a very small proportion of hemorrhages, not owing to external vio- lence, which would prove fatal, though no means were used to stop them; and hence it has happened, that a great number of other ex- ternal and internal medicines have been very undeservedly advanced to the rank of specifics in this complaint. Saccharum saturni has appeared to me to have the best title to be called an internal specific: and it is very unfortunate, that the useful quality of this, and other preparations of lead, should be joined with others of such a dangerous nature ; for I hardly ever saw a case, in which the probable good to be expected from them as styptics, would counterbalance the many certain mischiefs arising from their internal use. ENG LISII INDEX. PAGE PAGE Abdomen 14 Hemorrhage . 211 Ague 80 Headache . . 45 Aneurism 16 Headache, intermitting . . 48 Angina pectoris 152 Head, water in 93 Ascarides . 32 Hectic Fever 82 Asthma 33 Hiccup 169 Bath Water . 37 Hip, disease of . 51 Hooping Cough 181 Bowels, inflammation of 112 Hydrophobia 94 Bowels, pains of . . 119 Hypochondriacal and Hysterical Af- Breast, pains of . 125 fections . 97 Breasts . . 152 Bristol Water 40 Jaundice, and Diseases of the Broken State of Health . . 182 Liver . 102 Bronchocele . 40 Itch .... 53 Carbuncle 49 Itching of the Skin . 164 Catalepsy . 152 Chicken-Pox . 186 Legs, diseases of 51 Child-bearing 1G5 Loins, pain in . 123 Cold and Catarrh 62 Lymphatic Glands 124 Colic of Poitou 161 Consumption Cough . 156 180 Madness . Measles . 117 133 Diabetes . . Diarrhoea Diet Dropsy . 64 66 9 94 Menstrua Method of curing Diseases Miscarriage Mouth, disorders of . . 127 10 . 14 122 Drunkenness 70 Dysentery 69 Nettie-Rash Nose bleeding 76 137 Ears, disorders of Epilepsy 36 71 Numbness Nyctalopia, or Night-blindness . 178 141 Erysipelas, or St. Anthony's Fire 75 Eyes, disorders of *. 138 Pain 67 Pains, wandering 69 Fainting 122 Palpitation of the Heart 142 Fever 78 Palsy and Apoplexy . 143 Fingers, nodes of 67 Pancreas diseased 192 Fistula . 87 Pedicularis Morbus ■ 155 Flatulence . 117 Phlegm 163 Fluor Albus 88 Piles . 91 Pregnancy 90 Giddiness 192 Prostate Gland scirrhous . 164 Gleet . 90 Pulse 207 Gout 21 Purple Spots 165 214 ENGLISH INDEX. PAGE Rectum • 15 Strangury . Rheumatism 166 Suppression of Urine Rheumatism Chronical 205 Suppuration of the Jaw Rupture . 93 Swallowing • St. Vitus's Dance 50 Tenesmus Scald Head 59 Testicles . . Scarlet Fever 16 Thirst ■ Scrofula . 175 Thrush . Semen Virile J69 Tremor - Shingles . . 59 Sickness of the Stomach 189 Voice . Skin, diseases of . 53 Vomiting • Small-Pox 182 Sore Throat 18 Urine Spasms 171 Spitting of Blood . ■ . 172 Waking with Fright. Spleen diseased iyi Wens Stomach, pain of . 189 Womb, disorders of . Stomach, sourness of . 189 Worms Stone . 40 THE END. A TREATISE ON POISONS IN RELATION TO MEDICAL JURISPRUDENCE, PHYSIOLOGY. AND THE PRACTICE OF PHYSIC. By ROBERT CHRISTISON, M.D., F.R.S.E., Professor of Materia Medica in the University of Edinburgh, &c, &c. " We cannot but hail with satisfaction a new edition of this standard classical book. It merits are too well acknowledged for it to be necessary to say anything further in its behalf. Wherever Toxicology is known as a science, Professor Christison's Treatise is received as an authority of the greatest weight." — Lancet. " We have the pleasure of announcing to our readers the appearance of the fourth edition of this valuable treatise. Its character is so well established as a standard work in the Medical Literature of this country, that it needs no encomium from us. It is now fifteen years since the first edition of this work appeared, and it is only doing justice to it to assert that it has uniformly maintained its popularity as a work for re- ference and practice. It has, for a long period, been in the hands of barristers, who have not failed to make a good use of it in the cross examination of medical witnesses; and we believe there are few medical men who venture into the witness box on a trial lor poisoning, without having at least consulted it respecting some point on which Iheir evidence is likely to be impugned." " The fourth edition is well calculated to uphold the high reputation of its author." — Lond. Med. Gaz.for Jan. 1845. " Such is a most imperfect sketch of this most valuable work. It would be an ac- quisition to any medical library, and we think particularly so to our friends in this part of the world."' — New Orleans Med. Journ. "The First American from the Fourth Edinburgh edition of this unsurpassed work has appeared./ The American profession will have within their reach the ablest treatise in the language on the subject of poisons." — Western Journal. "The work of Professor Christison being recognised, by common consent, as the standard authority on this subject, it is unnecessary to do more than announce its publication."— New York Journal of Medicine. " It would be a work of supererogation, at the present day, to speak of the merits of this work. It has long and justly been regarded as one of our standard authori- ties." — Med. Exam. . . tt " Dr. Christison's is a very superior guide for the general practitioner and student. — Med. Chir. Rev. " A work abounding in original observations and opinions, exhibiting the science of Toxicology in its present advanced state, and entitled therefore to take the first rank in its cTass, is what might have been looked for from his pen."— West. Jour. ^£c(Jl Scigticcs. " We are free to say that it is the best book on the subject in the English lan- guage."— Western Lancet. " This book is of the very highest authority on the subject of poisons, and may be said to exhaust it."— Western Law Library. . " The author has, with singular industry, brought within the compass ol a single volume every variety of useful information and illustration connected with the subject. It is au'invalnbble addition to the Library of the Advocate." — Am. Law Library. Extract from a letter of Chief Justice Taney, dated Baltimore, July 28, 1645. " The whole subject is clearly and well arranged, and the symptoms, effects, and tests of different poisons very fully and plainly stated. Accept my thanks for the book. It cannot fail, I think, to be generally consulted and approved by those who, from professional duty, or any other motive, may be called upon to investigate the dimcult, and often painfully delicate subject, of which it treats." Extract from a letter of Judge Story, dated Cambridge, April 18, 1845. » I return you my sincere thanks for your kindness in presenting me with a copy of Professor Christison's Treatise on Poisons. It appears to me to be a most valu able and important work on the subject, and full of interest, not only to the medical profession, but to lawyers. I have rarely examined any book with more satisfaction ; and I shall certainly rocommend it to be purchased for our Law Library at Caui- |,rid"e 'as eniiin-ntlv deserving a high rtuik for the students of .Medical Junspru- dvuee.' N«'i can 1 doubt that it will receive the general patrouage of the public." Published by Barrington and Haswell. THEORY AND PRACTICE OF MEDICINE. Bell and Stokes. LECTURES ON THE THEORY AND PRACTICE OF PHYSIC- By JOHN BELL, M.D. Lecturer on Materia Medica and Therapeutics; Member of the College of Physicians, Philadelphia, and of the American Philosophical Society, etc., etc.; and WM. STOKES, M.D., Lecturer at the Medical School, Park Street, Dublin; Physician to the Meath County Hospital, etc., etc. Third American Edition, much enlarged and improved 2 vols. 8vo. sheep. " Few Medical works issued from the American press, within the same period, have had more currency, or been more highly approved by the profession. This edition of the Lectures is marked by substantial improvements, which will enhance the value of the work to the practitioner. Dr. Bell is just the man to keep his book up to the present state of medical science, and his readers have the comfortable as- surance that they have before them all the light of recent discovery."—Western Journ. of Med. and Surg. " Dr. Bell has bestowed much industry on the present edition. He has supplied many marked deficiencies in the former." " Those by our friend and fellow towns- man, to which we more particularly refer, exhibit much learning and research, judicious discrimination, and a thorough acquaintance with the diseases and practice of this country. More need not be said to entitle him to the thanks of the profession for his share in this publication."—Med. Examiner. " The first gentleman is known for his profound attainments, and the accuracy and ability which he brings to bear on all subjects on which the powers of his mind are exercised. The other, a resident of the city of Dublin, has rarely been excelled in writing on the practice of medicine. When the former editions were issued, a heartfelt pleasure was expressed at their appearance; and we have equal gratification in seeing that they were appreciated by the medical public — the evidence of which is certain, from the circumstance that this improved and enlarged edition is required to meet the demand. "These acceptable lectures are in two large, compactly-printed octavo volumes."— Boston Med. and Surg. Journ. " We cordially recommend such of our readers as have yet not supplied them- selves to procure a copy of the present edition of these lectures, for we feel confident that they will never regret the time as lost, that they may devote to their perusal. The work is gotten up in the usually neat and appropriate style of the enterprising publishers, and printed on good paper and clear type."—N. Y. Journal, of Medicine. "With such additions and improvements, we consider the work one of the best of its kind willi which we are acquainted."—Maryland Med. Sf Surg. Journ. " The work has now assumed the form of a quite complete system of medicine, equally valuable as a text-book to the student, and a book of reference to the practitioner." " We know of no book of the kind which we would more readily place in the hands of a student, or to which we would more readily refer the practitioner, for a hasty investigation of a subject."—NewEng. Quart. Jour " Our favourable opinion has already been expressed, and we will only add, that our estimate of their excellence has been heightened by repeated examinations. For all the qualities which the student or practitioner can desire in a work for study and reference, these lectures may be safely recommended, as comprising as much n» could be brought within their limits of sound opinion and judicious practice."__ West. Jour.