Chapter V: Part 5

When either the inflammation of the joints has commenced in the usual manner, but without an adequate degree of pain and inflammation, or at least without continuing the usual time, and precipitately recedes, some internal organ is exposed in its retreat and rebound. Or when the arthritick fuel is occluded, and not ejected to the feet, it will, according to the various parts and organs affected, excite corresponding vibrations and symptoms in the natural, vital, and animal functions; as inappetency, indigestion, nausea, vomiting, flatulence, ventricular eructation, colick, diarrhœa, nephritis, and urinary obstructions; difficult respiration, asthma, palpitation, fainting, general debility, low spirits, hypochondriasm, cramps and spasms in the muscles, apoplexy, palsy. In dubious cases from what source to derive such irregular alarms and minatory explosion; if they happen about the usual arthritic periods, and in such temperaments, their origin may be suspected: and it is of the highest moment to know that they are rarely of an inflammatory nature. After the disease has continued many years with frequent reiterated paroxisms the joints do not soon recover, but continue weak and stiff. In many cases, chalky and calculous concretions are formed in the joints of the extremities, and in the kidneys and urinary passages. Racked by those combined tortures, the patient requires the auxiliary aid of stuffed chairs, flannel, and crutches.

The predisposing and occasional _causes_ are hereditary; inactive sedentary life, with luxurious living and gormandizing, especially on animal food; intemperance in wine, spirituous or fermented liquors; early or intemperate libations to Bacchus and Venus; unremitting application to study or business; sedentary life; nocturnal lucubrations; disturbed sleep, cares, misfortunes, vexation, depressing passions; ceasing of usual exercise or labour; sudden transition from an active to a sedentary life; coaches, dissipation, luxury, effeminacy; sudden violent changes in diet; plethora; suppressed evacuations; profuse evacuations; various causes of debility; indigestion from quantity or quality of aliment.

_Of internal suppuration_ in the lungs, liver, stomach, intestines, kidneys. Pulmonick suppuration, empyema, or vomica, may be predicted from preceding inflammation, without considerable remissions, the neglect of effectual remedies, and no signs of resolution by the efforts of nature or art, and by remission of acute pain; the difficulty of respiration and also cough continuing; with frequent horrors and shivering, heat and hectic, weight and throbbing in the side, laying on the diseased side painful; dyspnœa aggravated by a recumbent posture; disagreeable taste in the tongue; thirst; fetid breath; emaciation. It may burst in all the intervals between fourteen and sixty days, and either relieves or suffocates, or is gradually expectorated: and sometimes, after absorption, may be evacuated by diarrhœa or urine: the purulent contents may also be discharged upon the diaphragm, or between the pleura and intercostal muscles. Sometimes there are several small abscesses; and too frequently the final termination is ulceration and phthisis. Suppuration in the Liver is a frequent consequence of previous inflammation, and is not altogether so fatal as some other internal abscesses. Its symptoms are those in common with internal formation of pus, horror and chilliness, hectic heat, thirst, weight and load in that region, jaundice-colour of the eyes. Sometimes the purulence erodes the external integuments; sometimes the diaphragm, lungs, or stomach; sometimes is discharged by the biliary ducts into the intestines, or absorbed and washed away with the urine. Suppuration in the stomach and intestines is rare. In the kidneys, the general symptoms, with purulent fetid urine: it may also burst externally; or by slow ulceration and hectic, undermine the constitution.

Of _Internal Gangrene_ in the lungs, stomach, intestines, kidneys, liver. Pulmonick gangrene from inflammation, is predicted by sudden cessation of pain, without any benign crisis: expectoration either suppressed, or yellow, green, black, and fetid; hollow noise in the breast during respiration; dejected countenance; red and heavy eyes; foul and black tongue; quick, languid, and intermittent pulse; fetid urine, stools, and sweat; hiccup; cold sweats; universal debility and sinking of the vital powers. From the preceding symptoms, from those enumerated under general febrile prognosticks, and from the functions peculiar to the different diseased organs, internal gangrene in whatsoever part may be comprehended; and a minute detail would be superfluous.

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_Diseases of the Lungs and Organs of Respiration_, what extensive ruin do they yet spread! In commenting upon these, I shall, in a trifling degree, invert the prescribed order and arrangement. Into this group are concentrated pulmonick hemorrhage, pulmonary phthisis, the various species of hectick, atrophy and tabes, nervous, sciatick, dorsal, and icterick; also asthma, dyspnœa and cough, catarrh, hooping cough, croup. Inflammation of these organs and spurious peripneumony, have already been described. These, therefore, constitute nearly the whole combined pulmonick host, and likewise some of those diseases closely connected with the pneumonick machinery, or with several of its general morbid symptoms.

Behold here one of the great caravans of dead to the stygian ferry; and tottering myriads crowding to the same shambles. View the innumerable multitude of fable mourners and weeping relations attending them in the last melancholy offices of friendship, to that eternal bourn, the grave! Every introspection of general morbid registers, and the unanimous observations of the medical profession, concord in proclaiming the notoriety of the consumptive throng, and their ruinous uncontroulable domination. Notwithstanding the prodigious improvement in the alphabet, subordinate rudiments, and appendages of the medical science, consumption as yet is one of the great oligarchy of morbid and remorseless tyrants. He would be intitled to every terrestrial honour, and to posthumous apotheosis; he would rival and eclipse the most celebrated tyrannicides, and expurgators of monsters, whether demi-gods, heroes, or saints, who could dethrone or controul this stationary monopolizer of human sacrifices, and sheathe his deadly sword.

From one fifth to one sixth of all the mortality in London, is from consumption; which is nearly double to that even of small pox. But consumption is a term too lax and indefinite. Into this gulph, no doubt, are thrown many febrile and slow hectick emaciations, from infancy to old age, in both sexes; and there are few diseases from acute and chronic sources, especially in their fatal termination, without emaciation. Consumptions and dropsies are the final wreck of a great variety of human maladies. In no two other diseases are, what pathologists term _Morbi a Morbis_, more apparent: and in multitudes of such cases, morbid dissections often detect the effect, and not the original cause. How many of the genuine pulmonary phthisis are consociated with this miscellaneous crowd, is difficult to guess; but, from the concurrent testimony of physicians, and of experience, we may safely affirm a very large proportion. There are few families in this kingdom whom it has not, one time or other, plunged into tears. Physicians on the continent alledge, that phthisis is more prevalent in Britain than in any other kingdom of Europe.

The next inquiry is, in what age, sex, rank of life, season of the year, and whether in city or country is consumption most predominant? It has been, from the earliest chronology, the universal echo and monotony of medical writers, to mark the principal consumptive age between 18 and 35. But, with submission, I would considerably enlarge its limits, including from birth to 5, and from 20 to 60. No age or stage of life is exempted; but we might “_a priori_,” and from viewing the great and general scale of mortality, assert, that between 5 and 20, a considerable number cannot possibly be swept away in the phthisical torrent. Nor do we mean to invalidate the general aphorism, that in the blossom and full maturity of vigour and comeliness, phthisis is superlatively deleterious. Between the sexes no distinction seems to be made. I conceive, however, that amongst the lower orders universally, and more especially those penned up in the foul atmosphere of cities, that phthisis is more fatal than amongst those who browse in the pure air of the country. In accommodation, cloathing, noxious trades, &c. the indigent have the disadvantage; and during sickness, from the same causes, their recovery is more desperate. With respect to seasons, winter and autumn in our climate is the most pernicious to pulmonick maladies.

_Pulmonary Hemorrhage_, hæmoptysis, sputum sanguinis. The lungs spungy pneumatick and hydraulick organs, in themselves passive; but by the contraction of the diaphragm and intercostal muscles enlarging the capacity of the thorax, this ventilator is alternately distended with atmospheric air, and this sonorous fluid again quickly expelled, with either some noxious emanation from the body, or decomposition of its own vital principle. Half the blood of the human body circulates thro’ this organ: its blood-vessels are numerous and large, and rise immediately from the heart; and it is incessantly in motion and agitation. When the body has nearly attained its ultimate extension and altitude, pulmonary hemorrhage is most predominant; more especially in those of narrow thorax, prominent scapulæ, red cheeks, and acute tone of voice. Before the hemorrhage, there are shivering, horror, heat, fever, weight, oppression, pain and heat in the breast, difficulty of breathing, titillation of the fauces, dry cough, exspuition of florid blood in various quantity, and slowly or suddenly, from ounces to many pounds, or even quarts, in a few days; but the latter is rare. It may soon totally cease, or only intermit, and again return at irregular intervals. Relapses are frequent on any irregularity or intemperance; on acceleration of the circulation, or expansion from heat.

This hemorrhage is very seldom in such quantities to prove precipitately fatal, unless mismanaged. From Bleeding, at least in the London registers, there is petty spoliation. Pulmonary hemorrhage is more frequently the consumptive precursor. Malign omens are an eruptive torrent; ulceration in the lungs; fever renewed; pain in the breast; difficulty of breathing; cough, hoarseness; night sweats; peripneumony; visceral obstructions; cachexy; old age; relapses. But pulmonary hemorrhage from temporary obstructions of the menses, or in pregnancy, or periodical, or without load in the thorax, or fever, are much less mischievous.

_Pulmonary Phthisis._ Not one hundredth part of pulmonary consumptions commence with hemorrhage. Phthisical lineaments are emaciation, diurnal hectic fever, obstinate rebellious cough, difficulty of breathing, and usually some change in the voice. In the beginning, phthisis often resembles a catarrh, or stubborn cold; and in this insidious disguise is too frequently slighted, or neglected: but continuing longer than the usual catarrhal period, without any considerable intermission, and especially if in summer, are sufficient grounds of alarm. In that, from tubercles, there is frequent teazing dry cough, exasperated at night; some difficulty of breathing, and panting on ascending any eminence or stairs, or on exercise; some emaciation and weakness. By degrees, there is more or less expectoration of viscid, yellow, greenish purulence, intermixed, however, with natural mucus, and in the progress streaked with blood. Sooner or later, uneasiness in the breast, inability to lay on one side, pain in the side, or under the sternum, and aggravated by inspiration and coughing.

The consuming hectic fever has generally two exacerbations during the twenty-four hours, about noon and night; with some degree of chilliness and shivering, and increased sensibility to cool air, notwithstanding the skin is preternaturally hot; the palms of the hands and soles of the feet burn; a florid redness, or circumscribed spot is perceivable in the cheeks; the other features are partial sweats about the neck and breast, particularly in the morning; disturbed sleep; slender, hoarse, and obscure voice; quick pulse; sometimes vomiting after meals; thirst; salt taste in the mouth; cough and expectoration, in frequency and quantity, varying in different persons; in some, there is a very considerable discharge of purulency from the lungs. Various ordeals have been proposed for the distinction of mucus from pus, or pulmonick ulceration. Mucus is naturally more transparent, viscid, and cohesive: pus always opake, more yellow and greenish; the odour more disagreeable, and the expectoration accompanied with a hectick fever. The sinking or swimming in water of the expectorated matter, is a precarious symptom, as it depends on the quantity of entangled air.

In this island, phthisis, especially from tubercles not suppurated, may continue one, two, or more years; appearing during the winter and spring, and disappearing during the summer. Other consumptions are much more rapid; in the vernacular phrase, galloping the patient to a skeleton in a few months. Phthisical patients are rarely confined to bed, until near the deplorable stages and fatal termination. Some have even a tolerable appetite; and the generality are cheered with adulatory hopes of recovery to the last extremity. The progressive encroachment is evident, by increased debility, emaciation, and partial sweats; edematous ancles; diarrhœa; depilation; consumption and melting away of the fat and muscular flesh: at last sapless, and macerated into ghosts, the twinkling vital snuff is extinguished. It is, as yet, impossible for me to apportion the comparative mortality and recovery in real confirmed phthisis; nor could I depend upon any of the general registers which I carefully consulted with this view. We may, however, venture upon a gross estimate, by negative proof. Exclusive of individual evidence, and medical attestation, we might, by a simple algebraic process out of any specified number, with their mortal diseases, and probable proportion of sick in each, sift out the consumptive. At all events, it cannot possibly be thought exaggeration to alledge, that not one out of seven consumptive recover. From hereditary entail, or tubercles, it is still more desperate.

_Species of Consumption_ are, hectick fever, atrophy and tabes; nervous; icterick; dorsal. Hectick fever and atrophy is described as a very frequent and fatal disease of infants, especially in cities; accompanied with emaciation, often short dry cough, hot skin and palms of the hands; quick pulse, thirst, diurnal exacerbations, sickly countenance: in some the abdomen is tense, tumid, and considerably enlarged. In simple atrophy the fever is not so acute; with tumid belly, irregular fecal discharge; voraciousness, indigestion, thirst, nocturnal sweats, unhealthy countenance. Atrophy and nervous tabes are confounded in medical diagnosticks: in both there is emaciation; but no considerable fever, cough, or difficulty of breathing; impaired appetite and digestion; leucophlegmatic sickly appearance, partial sweats; general debility, and proneness to faint on any exertion. Sometimes atrophy is circumscribed to a particular part or member. The icterick tabes is accompanied with symptoms of jaundice; and probably, under several disguises, is more frequent than medical authors have represented.

Dorsal, or spermatick, is a particular tabes; miserable spectacles of which are recorded by the celebrated Tissot. Its symptoms are, emaciation, yet good appetite; pain and weakness in the back and loins; disturbed sleep, and frequently interrupted by nocturnal dreams and pollution, either with or without pleasure; weakness of the knees and trembling of the muscles on the least exercise; sometimes a sensation as of thorns pricking the skin, and descending down the spine; pale sickly countenance, livid circle under the eye-lids; the feces and urine excreted with some difficulty, and often either with semen or prostate liquor. By degrees, the appetite decays with indigestion, hypochondriasm, melancholy; pains in various parts, headach, lumbago, universal debility, wasting of the penis, impotency and blight of future progeny. Females are not exempt from this disease; but it is much more frequent amongst the male sex, from the age of puberty through various adult stages of life: the foundation of it is often laid at schools; and in those seminaries of vice, large cities: and in some countries it is a more general habit of licentiousness than in others.

Of the predisposing and occasional _causes_ of pulmonary hemorrhage, pulmonary phthisis, hectick, atrophy and tabes. Of pulmonary hemorrhage; hereditary; narrow thorax; weak pulmonary blood vessels, small capacity; plethora; suppressed natural or habitual hemorrhage, as nasal, hemorrhoidal, menstrual; amputation of a considerable extremity; luxurious living and indolence; violent exertion and exercise of the lungs and voice in various trades and professions; also violent efforts to cough, to exonerate the excretories; parturition; lifting great weights; violent exercise; furious passions of mind: external injuries on the thorax; wounds; confining the thorax by writing-desks, by strong whalebone stays; suppressed perspiration and exhalation of the skin and lungs by cold; light atmosphere, especially on high mountains; pulmonick inflammation; scrophulous lymphatick glands and tubercles in the lungs, or calculous concretions; polypus concretions in the large pulmonary blood-vessels; schirrus and obstruction in the abdominal viscera.

The predisposing and occasional _causes_ of pulmonary phthisis are all the preceding causes of pulmonick hemorrhage; hereditary; scrophulous tubercles; suppuration in the lungs, and not with laudable pus; calculi in the lungs; consequence of pulmonick inflammation and suppuration, of small pox, measles, hooping cough, rickets; and of various acute and chronic diseases; venereal, icterick; chlorosis; worms; rheumatism; chronic asthma; internal abscesses and ulcers; catarrh and neglected colds; sudden suppression of perspiration, especially when the body is heated; pulmonary exhalation suppressed, and cold damp air inspired; irregularity and coldness of the climate joined to moisture; various noxious trades and occupations; noxious fumes and effluvia inspired; foul atmosphere of cities, coal fires; broken ribs and blows on the thorax; indigence; cold habitations; want of sufficient cloathing and fuel in rigorous seasons.

The predisposing and occasional _causes_ of hectic, atrophy and tabes, are many of the causes just now enumerated: scrophulous obstructed mesenterick glands, and course of the chyle; colds; damp habitations; foul atmosphere of cities; moist cloudy atmosphere; unwholesome air; coagulated milk in the stomach and intestines; foul stomach; diseased stomach and abdominal viscera; improper diet; gluttony, sloth, uncleanliness, bad nursing, insufficient exercise; worms; repelled cutaneous eruptions and ulcers; cachexy; intoxication and intemperance; depressing passions of mind, cares, and vexations; intense study; insufficient nutriment, poverty, and want of food; frequent vomiting of food; faults in the organs of digestion; digestive fluids defective or depraved; profuse evacuations, as hemorrhages, diarrhœa, diabetes, fluor albus, salivation, seminal emission; delicate women suckling; sweats; rupture of the thoracick duct; diseases of the spinal brain; weakness of the solidum vivum; general defect of fluids, or of oil in the cellular texture; fever and absorption of the subcutaneous oil; old age and contraction of the small vessels; broken constitution, from various causes; frequent manustupration; libidinous books, prints; consequence of venereal gleets, and improper treatment.

_Asthma._ In the London bills, Asthma and Tissick are forced into a connubial link: formerly it was consumption and tissick, the Italian name for consumption, and without any mention of asthma. It would appear by the London registers, that about one fortieth part of the _memento mori’s_ in church-yards is from asthma; and its proportion to consumptive mortality as 1 to 8. I have every reason to believe that the funeral catalogue in London is not, in any outrageous degree, preternaturally overcharged with consumption or asthma. As both these diseases are properly excluded from in-patients of our hospitals, I applied to one of the largest dispensaries in London, the Aldersgate; in which there is necessarily an overflow of both these distempers; and with the intention of confronting and irradiating the bills of mortality. Almost every page of these books presented Asthma in no inconsiderable number; and above all, Phthisis, phthisis, phthisis, towering with gigantic bulk.

There is, unfortunately, in medical books such an exuberance of postulata, that I endeavoured to ascertain from facts and numbers, the sex and age in which asthma is most predominant; and also its absolute mortality. For this purpose I extracted and winnowed out of all the patients in the Aldersgate Dispensary during seventeen years, from 1770 to 1788, all the cases of asthma and dyspnœa: the result is as follows. Out of 70,000 patients, asthma and dyspnœa were 3,192; or one twenty-third of all the diseases; of which there were of males, 1613; females, 1536: dead, 169; relieved, 575: discharged, 569: cured all the remainder. The sundry ages of these were,—From birth to 10 years, 36; from 10 to 20, 25; from 20 to 30, 161; from 30 to 40, 429; from 40 to 50, 882; from 50 to 60, 949; from 60 to 70, 596; from 70 to 80, and upwards, 114.

From the preceding valuable records, and which, in this instance, happen to chime with the gross of medical observations, we may draw the following inferences: That in infancy and adolescence there are very few cases of asthma and dyspnœa: that these diseases chiefly occur in middle age and the decline of life: that more than one half of them are reported as cured; the relieved and discharged forming a neutral list, numbers of whom were either surfeited with medicines, or were discharged by their physicians when despairing of a radical cure, or fearful of their swelling the dead catalogue: in sinking of which there is a universal rivalship throughout our dispensaries and hospitals. Some of them, probably, were palliated, vamped, and amended; and indeed many were aged, for whom it would be unreasonable to expect a radical cure. I conceive, that with a part of them we may venture to double the dead list; which would raise asthmatick mortality to one of ten. But in the above estimate, what proportion legitimate periodic asthma bears to the other anhelations I could not fathom.

The term Asthma has been misapplied to every species of dyspnœa: it strictly denotes a chronic periodic difficulty of breathing, recurring and exasperated in paroxisms; and, at least in the intervals, without fever. Authors have subdivided it into several species; the spasmodic, convulsive, and periodical; the dry, humid, continued, flatulent: and from the gradations of difficulty in respiration, dyspnœa, orthopnœa. The periodick and spasmodick is the true disease. Generally, the day preceding the paroxism there is fulness of the stomach, impaired appetite, flatulence, eructation, tightness, and stricture about the breast, and difficulty of respiration; sometimes dry cough; the diaphragm descends with difficulty in inspiration: these are all increased by wine, fires, bed, and heat: the head is stupid, heavy, with slight pain, drowsiness, languor, yawning, restlessness of spirits; profuse excretion of colourless urine.

Asthmatic paroxisms commonly invade suddenly, or are greatly aggravated during the night, with constriction in the breast, anhelation and struggling in breathing, so that all the muscles of the thorax and shoulders are roused into action to enlarge the capacity of the lungs: this difficulty is greatest in inspiration: the patient is compelled to sit erect, or recumbent in bed, panting for breath, cool air, and drink; and can with extreme difficulty cough, expectorate, or speak: the respiration is slow, laborious, wheezing, and sonorous; with painful propensity to cough: from the interrupted circulation of blood through the lungs, the face and eyes are turgid and livid, in some the face is pale and bloated; with headach, somnolency; palpitation of the heart; weak and intermittent pulse; internal burning heat, and often cold extremities; eructation and flatulence, sometimes vomiting; difficult and sonorous deglutition; sweats; limpid urine; restlessness, or disturbed sleep. Some lay easier on one side than on the other. Many are under the necessity to sit erect in a chair during several days and nights, gasping for breath, not daring to repose in bed. Should both lobes of the lungs be equally constricted, the compound offices of this pneumatick and hydraulick organ will be obstructed, with more threatening symptoms of suffocation and strangling. A loaded stomach, close chambers, fires, beds, wine, noxious smells, all aggravate the paroxism.

In the duration, recurrence, intermission, and remission, asthmatic paroxisms vary. A few hours, or a few days, are the usual limits of this pulmonick tumult. In the beginning it continues only a few hours, with a diurnal remission and nocturnal renovation: in the chronic state, from two to five days is the usual duration. As the paroxism mitigates, there is flatulent explosion upwards and downwards, often with fecal discharge, and expectoration of mucus. The intermissions are proportioned to the duration of the paroxisms: the longer the paroxisms the longer the intervals, and _vice versa_: with a copious expectoration they sooner terminate, and are less severe. Some have had as many paroxisms in winter as in summer; and in the country as in town. Floyer had sixty in winter and twenty in summer: the latter, as usual, were more violent, and longer. During calm frosty weather asthmaticks are most secure; but at all points of the compass the paroxism may invade. Some find more ease in the city than country; others, in low ground than mountainous. Some are never entirely liberated from dyspnœa, and with periodical aggravations. Few, comparatively, die immediately in the asthmatic paroxism: numbers survive many years, even to the goal of longevity, and, emaciation excepted, without considerable diminution of strength, spirits, or appetite. After long continuance, it seldom admits of a radical cure; but only alleviation and respite. Its fatal terminations are suffocation, apoplexy; pulmonick inflammation; consumption, cachexy, partial or general dropsy; polypi in the heart and the large vessels.

The predisposing and occasional _causes_ are hereditary; original structure of the pneumonick organs; narrow thorax; plethora; suppression of habitual or natural evacuations, and cutaneous eruptions, as menses, piles, old ulcers, sweat of the feet; consequence of catarrh and colds, and sudden suppression of perspiration: serum, pituita in excess; cachexy; dregs of fever, small pox, measles, and pulmonick inflammation; pulmonick tubercles; spasmodic stricture of the diaphragm and bronchiæ; smoky rooms and houses, especially with wood fires; noxious mineral and metallic fumes, arsenical, nitrous, sulphureous, saturnine; smoky atmosphere of cities; pulverulent trades, as stonecutters, lapidaries, millers, flax-dressers, chimney-sweepers; fetid offensive smells; sudden changes of weather and winds from heavy to a light atmosphere, portending storms, and especially snow; easterly winds; fogs, with unsteadiness of weather and seasons; possibly some secret alterations in the electrick fluid, and affecting electrometers; warm and moist air; errors and intemperance in food and drink, and ingurgitation; violent motion and agitation of body and of mind; symptomatick in various diseases, as hystericks, hypochondriasm, gout, pectoral dropsy, empyema, polypi in the heart or aorta; wounds of the lungs; diseases of the liver and spleen.

_Dyspnœa and Coughs_ are symptoms of many diseases; and they are also primary, and very general maladies, especially in this island. It is true, we have here no compass to steer by: these are an exploded banditti; a sort of rebels to the symmetry of system, whose diagnosticks and therapeuticks are as yet slovenly and imperfectly noticed by medical authors. From the universal connection of the organs of respiration, their functions are more or less interrupted by and warped with other diseases and morbid symptoms. Many of the chronic impediments in breathing, and the broken-winded, may be called asthmatic excrescences, without its periodical paroxisms, exacerbations, and remissions; and without any rapid emaciation or hectick: they are spurious asthmas and chronic catarrhs. All the parts about the fauces and pharynx are crowded with mucous glands, from which, as in angina and catarrh, there is often a profuse secretion. Many persons advanced in life, and the aged, have a large discharge of mucus, variously, from the fauces, pharynx, larynx, lungs, stomach; all requiring frequent expectoration or hawking. The predisposing and occasional _causes_ are many of those already enumerated under consumption and asthma. To these may be superadded cold pituitous temperament; air hot, cold, weighty, light, moist, impure, stagnant; changes and vicissitudes of the winds; cold moist climate and atmosphere, and especially in winter, autumn, and spring, and interchanges of the seasons; sudden vicissitudes, disorders and inconstancy of the surrounding elements; suppressed perspiration, and pulmonary exhalation; catarrhal defluxion on the lungs, larynx, fauces; mucus in excess, tenacious; faults in the mucus glands and ducts; trachea too sensible or irritable; calculi, chalky concretions, and inspissated mucus in the larynx; vascular or parenchymatous diseases of the lungs; original faults of the lungs, bronchiæ, larynx; wasted lungs; extravasated air; spasm of the respiratory muscles; flatulent farinaceous food, slimy food, and drink; weak or foul stomach, voraciousness; infants swallowing saliva; symptomatick in various diseases of the thorax, as consumption, asthma, empyema, polypus, aneurism, _cum multis aliis_: symptomatick in various diseases of the abdomen interrupting the play of the diaphragm; as full stomach, flatulence; pregnancy; dropsy; enlarged spleen or liver; tympany; nephritis; worms; injured abdominal muscles.

_Catarrh_, colds, influenza, coryza, gravedo. In our irregular climate, during the annual revolution of the seasons, few escape slight catarrhs and colds, to which all ages are liable. That particular epidemick species of erratick catarrh, called Influenza, has sometimes spread suddenly over a kingdom, and some the greatest part of Europe. In no other epidemick do so few die in proportion to the number infected. Its continuance is generally short; and the little depredations committed during its itinerant incursions, are principally upon declining, consumptive, asthmatick, those of diseased lungs, worn out constitutions, and aged. In such forlorn complaints, catarrhal influenza has hastened the final dissolution sooner than it would otherwise have happened. In some, from neglect or irregularity, it has excited consumption, or pulmonick inflammation: in others, recovering from fevers, and convalescents of various descriptions, it has occasioned relapses. These observations are also applicable to simple catarrh skirmishing in less formidable inroads. Frequent relapses, from imprudence, in persons of phthisical or asthmatic constitutions, may expedite the inflammation of latent tubercles; or in aged persons subject to pituitous coughs, spurious peripneumony.

Catarrhal symptoms are increased secretion of mucus, from the membrane of the nose, fauces, and bronchiæ, with slight fever. It generally begins with some difficulty of breathing through the nose; dull pain and weight in the forehead; oppression in moving the eyes; distillation from the nose, sometimes from the eyes, of a thin fluid, often acrid, and exciting frequent sneezing; lassitude and languor of the body and spirits; sometimes shivering and heat, and increased sensibility to cold air; hoarseness, soreness of the trachea and fauces, with some difficulty of breathing, frequent cough and irritation at the glottis, at first dry; sometimes slight inflammation or angina, and pains resembling rheumatic about the neck and head. In some, the appetite is impaired, but not considerably; but in all the smell and taste. By degrees, the cough and sternutation are accompanied with a copious excretion of mucus, progressively incrassating, with less laborious efforts of coughing and hawking. Some catarrhs or colds, affect principally the membrane of the nose, and the different sinusses or cavities communicating with that emunctory; wherein stagnating mucus becomes more tenacious: others are lower situated in the fauces, pharynx, and trachea. Catarrh seldom continues beyond a few days, or weeks: that from contagion is more febrile and chronic. The predisposing and occasional _causes_ are, cutaneous perspiration and pulmonary exhalation suddenly checked; cold moist atmosphere; sudden atmospheric changes; cold habitations and beds; wet feet; head or breast exposed or naked, thin ragged clothing; excessive effeminacy and warm rooms; epidemick state of the air.

_Hooping Cough_, chincough, tussis convulsiva, epidemick, and contagious: is generally prevalent in infancy and adolescence, and but once in life: adults are rarely afflicted with it; and it is not confined to any particular season of the year. In the London registers, hooping cough and cough are confounded, and conjointly make no inconsiderable augmentation to the funerals. By the records of Dr. Armstrong in the dispensary of infant poor, of 732 cases of hooping cough, only 25 died; that is, about 3½ _per cent._ or 1 of 33. But this is too favourable a representation as a general scale of mortality. Its beginning resembles a slight catarrh continuing some days, or one, two, and three weeks before the formation and maturity of the convulsive paroxisms. These consist of many successive expiratory motions, so as to exhaust the lungs of air, succeeded by a full inspiration and pulmonick gulp, which rushing thro’ the glottis, makes a particular loud hooping sound. The duration of these pneumonick convulsive paroxisms, is from one to several minutes, in which the child’s face is turgid with blood, tears trickle down the cheeks, and it seems almost in the agony of suffocation and strangling. At the termination of each paroxism there is usually some mucus expectoration and excreation: this, at the beginning, is thin and not considerable; but by degrees increases in quantity and tenacity; and frequently at the same time, the contents of the stomach are evacuated. The pneumonick convulsions vary in their recurrence: they often return, frequently in the course of twenty-four hours, especially during the night: and thus may continue to persecute from one to three months, and sometimes a much longer space. Throughout, the senses are not injured; nor in the beginning the appetite; and in the intervals, children return to their amusements as if nothing had happened.

The younger the child there is more danger; as also in those born of phthisical or asthmatic parents, or in a state of debility, when seized with the hooping cough. When it begins in the form of catarrh, and is attended with fever, difficulty of breathing, and little expectoration, it may prove fatal in the early immature stages, unless the convulsive cough supervenes, and with copious expectoration. After some continuance of the disease, fever, with nocturnal exacerbation and difficult respiration, sometimes occur, and always with danger. Some fall down in the paroxisms; others have convulsions: violent paroxisms of coughing have excited epilepsy, apoplexy, or suffocation; but fever, dyspnœa, and pulmonic inflammation are to be most dreaded. With moderate expectoration the paroxisms are neither frequent nor violent: but expectoration in either extremes of scantiness or excess are both unpropitious, more especially with dyspnœa. Paroxisms terminated by vomiting, and succeeded by craving for food, are favourable omens; and recovery may be predicted by longer intervals from coughing, and shorter paroxisms; by restitution of natural appetite and respiration, of tranquil sleep, of fecal excretion, by evanescence of fever, and recruit of strength. The predisposing and occasional _causes_ are, a certain epidemick state of the air or specifick contagion, the nature of which, and in truth of the disease beyond empirical observation, are as yet very imperfectly understood.

_Croup_, suffocatio stridula. This disease has been particularly discriminated by modern authors. It is principally inimical to children, seldom until after ablactation; and never after the age of twelve, or of puberty at the utmost: it may attack the same child more than once: it is most frequent in winter and spring; and is not contagious nor general amongst the community. It commonly invades like a catarrh; and sometimes with its own permanent features, which are sudden paroxisms, as in spasmodic asthma, of laborious struggling respiration, and wheezing, as if the air-passage was straited; hoarseness, and shrill ringing sound, both in coughing and speaking, as if the voice came through a brass tube; cough, if any, dry, or with excreation of membranous fibres; thirst, quick pulse, anxiety, restlessness; and during the intervals, the senses and appetite are unimpaired: sometimes there is appearance, sometimes none, of inflammation in the fauces. It is always dangerous, infinitely more so than the preceding disease: death may suddenly ensue on the third, fourth, or fifth day, and perhaps when no such event was suspected: the impending hurricane may be prognosticated by laborious struggling in respiration, and symptoms of strangulation; with anxiety, restlessness, quick weak pulse.

The predisposing and occasional _causes_ are yet the subject of litigation; whether inflammatory, or spasmodick, or a combination of both. On dissection, mucus accumulated has been found lining the larynx, by degrees incrassating, and interrupting the air from entering the lungs. We require same additional illumination on this subject.

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A Miscellaneous cluster of diseases are now to be developed. In the majority of these, however, some few general features of affinity may be traced: such as their affecting, directly or collaterally, the head, the brain, or its numerous diverging chords, the nerves; or the inherent muscular energy. But in many other circumstances of cause, diagnostick, prognostick, and therapeutick, they are disunited. And in every possible arrangement such defects are irremediable.

_Headach._ No parts of the human organization are more prone to transitory interruption and disorder than the head and stomach: between the two there is a close connubial sympathy: to these two important centers many other maladies and remote perturbations converge, or reverberate their affliction. We here treat of headach as a primary disease; or at least as the principal symptom. From this calamity, in the extreme, the lives of many are rendered wretched. The London bills neither convey an adequate representation of cephalgick fatality, and far less of its general contentious torture of the human species. Headach has been subdivided by authors into the idiopathick, symptomatick, general, local, internal, external, chronic, periodic, and temporary; into cephalea, cephalalgia, hemicrania, clavus, megrim. In the seat, duration, recurrence, and pain, there are many varieties and gradations. Trespassing on the throne of sensation, it is evident the corporeal and mental functions must lament the subjugation.

The predisposing and occasional _causes_ are, hereditary; sanguineous plethora; suppression of habitual hemorrhages, as menstrual, hemorrhoidal, nasal; perspiration checked; cold feet; cutaneous pores blocked up, and not sufficient perspiration; stomach foul, disordered; food or drink disagreeing; gluttony; ebriety; unwholesome quality of fermented or distilled liquors from accident or design; costiveness; violent exercise of body or mind, voice and lungs; immoderate determination of blood to the head from causes corporeal or mental; much stooping of the head; disagreeable passions and anxiety of mind, exasperating or depressing; study in excess; state of the winds and weather; of the points from whence winds blow; the variations in the barometer and electrometer; the muddiness and fogs of the atmosphere; cold; heat; foul air; crowded rooms, theatres, and other assemblages of mankind for amusement or business; offensive smells and vapours; fainting; inanition; excessive evacuations; intermittent; rheumatick; arthritick, hysterical; nervous; scorbutic; impure blood; cachexy; venereal; lunar; caries of the skull; diseases in the diploe; abscess, insects, or inflammation in the frontal, ethmoidal, or sphenoidal sinusses; first branch of the fifth pair of nerves particularly affected; carious teeth; various diseases within the brain; external injuries: symptomatick in fevers; hydrocephalus; and many other diseases besides those above enumerated.

_Night Mare_, incubus, ephialtis, pavor nocturnus. Oppressed breathing during sleep and sensation of load in the breast, and of suffocation; terrifick dreams, fantasies, apparitions, visionary encounters, and dangers; by which the person is at length awaked in agitation, palpitation, and sweats. It attacks generally the dormant in a supine posture. Some infants and children, during sleep, are also disturbed with anxious groans, and exclamation. The predisposing and occasional _causes_ are, plethora; heavy suppers; ventricular crudity, indigestion, gluttony, flatulence; worms; head laid low in bed; intense application of mind, and various passions: symptomatick in some fevers, in hystericks, hypochondriasm, hydrocephalus, hydrothorax, aneurism, and polypi; sometimes is a prelude of apoplexy, epilepsy, &c.

_Apoplexy._ Under this we shall aggroup several inferior species of vortex and stupor in the imperial seat of reason and motion; as lethargy, coma, carus, cataphora, vertigo. By apoplexy and suddenly, in the London registers, between one eightieth and ninetieth part of the community seem to be destroyed: and this mortality would be magnified by the addition of many who are reported as found dead. In the last 30 years of the preceding century, apoplexy and suddenly stands at 3010: Lethargy at 488: and megrims now omitted at 45. This thunderbolt of death, or in the phrase of one of the British poets, “that knocketh man down as butcher felleth ox,” is principally hostile to those advanced in years, and the aged: to those more especially of large heads and short necks, of corpulent habits, indolent life; to the full feeders, or the addicted to frequent intoxication. Medical observations also represent it as affecting more of the male than the female sex; as more predominant in winter and spring, especially on vernal heat succeeding winter cold; or moist rainy weather supplanting cold, and _vice versa_. It is also said to be more general and fatal in the city than the country.

Apoplexy may attack suddenly; in other cases it is preceded days, weeks, or even months before the shock by vertigo, obscure vision, noise in the ears, dullness of memory, faultering in the tongue, difficulty of articulation; in some the mouth is distorted, with transient torpidness or tremor of different muscular parts, headach, drowsiness, night mare, nasal hemorrhage, flushing of the cheeks, lachrymation, decay of strength, alteration of countenance and voice. In the paroxism the patient, instantaneously stunned, falls down, with suspension of the functions of the external and internal senses, of voluntary motion, and of voice and speech; and with muscular relaxation; at the same time the pulse and respiration remain nearly in the natural state, excepting that there is generally a stertor in breathing, resembling a profound sleep from gross intoxication; and also, as in most soporous diseases, the circulation slow. These unmolested functions of the heart and lungs distinguish it from syncope. In the duration and severity of the symptoms, there are different gradations. Some lay in this lethargic state insensible to every object and impression: some when spoke to, only groan or make dumb signs: some, after a short time, are able to articulate: in some, there is froth at the mouth: the colour of the face is various, sometimes flushed, sometimes however pale; and the signs in authors between the sanguine and serous apoplexy are extremely ambiguous.

It often proves fatal at the first stroke; few can survive many attacks. Death, recovery, or transition into palsy, are generally decided within seven days. In magnitude of danger, perhaps no other disease can contend with this formidable antagonist: but I shall leave it to others to graduate the apoplectick scale. Some recover; in others it ends in death or hemiplegy, which is but a sad alternative and capitulation for life: and too frequently is accompanied with some lesion of the mental functions. Even of those who recover, they are in danger of relapses from intemperance, and errors in the non-naturals. The violence and contumacy of the symptoms indicate the degrees of peril: the less the functions of internal and external sense, and of voluntary motion are injured, our hopes are more flattering; whereas total insensibility, froth at the mouth, cold sweats on the breast and face, cold breath, involuntary excretion of feces and urine, are harbingers of impendent wreck in the apoplectic whirlpool.

Of lethargy, coma, carus, cataphora. These denote different degrees of profound deep sleep without delirium. Authors have often confounded them with the febrile class, especially the “_lusus naturæ_” of remittents. To this irresistible torpor and drowsiness, even at meals or in conversation, many corpulent and fat persons are subject. We also read in authors of some extraordinary instances of profound long protracted sleep, from which it was impossible effectually to rouze the person. The vertigo has also been distinguished into simplex, scotomia, caduca. In this disease all objects, although at rest, seem to whirl round; sometimes with headach, flushing of the face, noise in the ears; and if not supported, the patient often falls down. It is commonly fugacious, and momentary; seldom above a minute; and in some diseases is symptomatick. The prognostick may be deduced from that of apoplexy.

Of the predisposing and occasional _causes_ of apoplexy, lethargy, coma, carus, cataphora, and vertigo: hereditary; short neck; plethora, general or partial, sanguine or serous, especially sanguineous plethora in the vessels of the brain; tight neckcloaths; pressure on the descending aorta, cava; serous or sanguineous exudations or extravasations in the brain; compression of the medullary substance, or of the origin of the nerves; suppression of habitual evacuations or hemorrhages, nasal or hemorrhoidal; habitual venesection neglected; old ulcers dried up; full and long continued inspiration loading the vessels of the head; blood forced on the brain by violent efforts of coughing, vomiting, fecal expulsion, exercise, venery, stooping the head; salivation suddenly suppressed by cold; foul stomach, gluttony, surfeits, luxurious living, and sedentary life; fatness, corpulency; intoxication, sottish potations; violent passions of mind irascible or stimulating, and also depressing, as anger, ambition, chronic melancholy and cares; intense meditation and study; intemperate lust in old age; noxious vapour from liquors in fermentation, from charcoal, quicklime, and new-plastered walls; particular effluvia and odours concentrated in large quantity; crowded rooms filled with animal steams from the lungs; thunder; sometimes epidemick state of the air and elements, or perhaps celestial influences not yet explained; intense cold; warm baths; blood rarified and expanded; insolation; some narcotick poisons, as opium, hyoscyamus, cicuta, laurus, belladonna, and some fungi: obstructed circulation through the lungs and heart, from asthma, polypi, ossifications of the large blood vessels or valves, and particularly of the right ventricle; external injuries of the head; concussion, fractures. The most frequent cause is, accumulation and congestion of blood in the brain: but sometimes, on dissection, no disease is discernible; and effusions in the brain do not always inflict apoplexy.

Of vertigo, the causes are several of those just enumerated: the principal, plethora, suppressed hemorrhages; suppressed perspiration; luxurious diet, gluttony, somnolency; foul or disordered stomach; costiveness; intoxication; narcotick and tobacco fumes; unremitting attention of mind to study or business; restlessness, mental distress; hunger, inanition, debility; obstructions and diseases in the retina or optick nerves.

_Palsy._ Paralysis, hemiplegia, paraplegia. During the last thirty years of the preceding century, paralytick mortality is only 630 in the London bills; but in the present century is doubled and trebled; and some part of this surge can be readily accounted for by the multiplication of the mechanical arts, in which lead and quicksilver are employed. At present, its mortality seems to stand in the proportion of one third or fourth to that of apoplexy. Of 310 patients afflicted with palsy and hemiplegy, and admitted in the course of 10 years into the Bath hospital, 57 were cured; that is, 7 _per cent._ or 1 of 15; there died 15, or 5 _per cent._; and the remainder were found incurable and discharged, or received some trifling relief; and several of these might be added to the dead list. I doubt whether by the artillery of the shops we are so successful against this crippling foe. A considerable number of the community are rendered helpless and decrepit from this disease; to which some trades, more than others, are obnoxious; and adults and aged infinitely more than the young and adolescent.

Palsy and apoplexy often alternate, and may then be termed one bicipitous disease. Severe apoplectick strokes, if not immediately fatal, frequently remit, and pass into palsy: or the catastrophe may originate in hemiplegy, which is the most frequent form of palsy; and when fatal, it is through the apoplectick explosion. In palsy there is more or less diminution or privation of muscular motion and feeling, without pain or fever, or injury of appetite. This may affect the muscles of voluntary and of involuntary motion; the whole, or only a portion of each: as muscular impotency of one side, or half of the body; of one or both of the lower or upper extremities; of some smaller portion of the face, eyelids, tongue, œsophagus, stomach, intestines, the sphincters of the bladder and anus, the penis, bladder, kidneys, heart. Under this deplorable calamity many linger years; some confined like a shellfish, and motionless; others crawling upon crutches. Tremor may be ranked as an inferior vassal of palsy.

The predisposing and occasional _causes_ of palsy are most of those of apoplexy; various diseases of the cerebrum, cerebellum, and medulla oblongata; diseases of the inherent muscular power; vapours from lead, mercury, arsenick; colica saturnina; compression of nerves; abscesses in the lumbar vertebræ; falls, external injuries, blows on the head or loins, luxations or sprains of the lumbar vertebræ; spinal dropsy; fractures; venery. Of Tremor many of the causes of apoplexy and palsy; hereditary; old age and decay of the inherent nervous and muscular energy; compression or obstruction of the nerves; poisons; opium; employments in lead and mercury; ebriety; suppressed evacuations; sanguine plethora; repelled cutaneous eruptions; lurking gout; general debility; external injuries; warm fluids; strong tea; excess of venery; long watching; anxiety; passions of mind; sedentary life; excessive evacuations.

_Epilepsy._ Morbus sacer, demoniacus, caducus, falling-sickness. In the last thirty years of the preceding century, thirty-five deaths only are marked in the London bills to epilepsy; and in the first forty-five years of the present century, they dwindle to thirteen: at present the title and disease is omitted. Medical men know, that no inconsiderable number of the community are tormented with this frightful convulsion, which the ancient Jews could only ascribe to the malicious rancour of an infernal devil. In this instance also, professional experience and erudition must interfere and correct the omissions of the publick registers. We are certain, that epilepsy is much more destructive to the springs of life: perhaps it is cast by the reporters into either the apoplectick or convulsive abyss. It is alledged to be more frequent amongst the male than female sex; and in infancy, in those of delicate constitutions, lax habit, acute, nervous and muscular irritability. _Vid._ Convulsions.

In many cases there is no previous monitory of the impending paroxisms; in some other cases the lowering storm is portended by lassitude, headach, giddiness, dimness of sight, broken sleep, frightful dreams, restlessness, terror, noise in the ears, palpitation of the heart, unusual smells, murmuring of the intestines, yawning, luminous flashes before the eyes, profuse urinary excretion, sense of the disease ascending from a particular part to the head. By the epileptic whirlwind the patient is suddenly and precipitously thrown down, with suspension of the internal and external senses, and universal convulsions of the external muscles, or those of voluntary motion: the muscles of the head, face, eyes, and mouth, are particularly agitated; the head is tolled in every direction, the teeth grind against each other, the eyes roll, the mouth emits froth and slaver; the tongue, thrust out of the mouth, is often wounded and lacerated by the teeth; the respiration is as if through a noose on the neck; the fingers are clinched into the hand; there is perpetual involuntary deglutition, palpitation of the heart, and sometimes involuntary excretion of urine, semen, or feces; the motions of the heart and of respiration are hurried, but not otherwise interrupted nor injured. Such is the powerful coercive muscular contractions and convulsions, that several strong assistants are requisite to secure each member. Some, at the first struggle and uproar, emit hideous groans or yells, resembling the bellowings of a wild beast; others, a more still and savage murmur. In most, the aspect is horrible: nor does any other disease exhibit such truculent spectacles of terror and abhorrence.

After some few minutes, very rarely hours, a pacification ensues, and abdication of the epileptic demon; and the patient liberated, rises up of his own accord, languid, dejected, and ashamed, with but few traces on the memory of the preceding tragedy; and nearly in the exercise of all his usual faculties; which is not the case in apoplexy. In the severity and duration, but still more in the repetition of the paroxisms, there is prodigious variation: in some they are erratick and irregular; in others, they are periodical; and at various intervals in diurnal paroxisms, synchronous with the tides; monthly with the lunar revolutions; equinoctial; annual. It is often a chronic disease, and then, much less inimical to life than might be expected from such a universal commotion. But in infancy, epilepsy and convulsions are the most atrocious of the morbid murderers. Sometimes it ceases after puberty. In old persons, or where there is no previous warning of the approaching paroxisms, the prospects are deplorable: reiterated epileptic bombardment often makes breaches in the internal recesses of the senses; hence insanity, apoplexy, palsy, idiotism. Authors have attempted the diagnosticks of epileptic origin: thus, in the brain, or its spinal elongation, it is represented as invading with stupidity, or hebetude of the internal and external senses; headach, disturbed sleep, pale face; with suddenness in the assault, without previous warning, and a sort of sensation of distillation from the head to the breast and stomach: from nervous sympathy of the stomach and intestines, and of the extremities, it is preceded by disturbance of those parts at the approaching paroxism; by an aura epileptica, and ascending vapour, or extraordinary sensation originating from some fixed point. To conclude, this convulsion is sometimes feigned by begging impostors.

The predisposing and occasional _causes_ are, hereditary, peculiar original organization, especially of the brain and its appendages: plethora, fright, terror, horror, anxiety and passions of mind, excess of venery, study; passionate drunken nurses; foul stomach; acidity, acrid bile; worms, dentition, scald head, or ulcers rashly dried up or repelled; external injuries of the head; various diseases within the brain, or in the nervous chords; ebriety; difficult parturition; hystericks; cachexy, dregs of intermittent fevers; irritability and sensibility in morbid extreme; nervous sympathy and motory vibrations; force of habit; offensive odours; poisons, narcoticks. In those of epileptic temperament and predisposition, paroxisms are liable to be recalled by heat, ventricular crudity, intoxication, anxiety and passions of mind, terror, prospect of precipices, &c.