* * * * sluggishness, vertigo, heaviness of the tendons, plethora and distension of the veins in the neck; and much nausea indeed after food, but also, not unfrequently, with abstinence, there is a faint nausea; and phlegm is often vomited; want of appetite and indigestion after little food: they have flatulence and meteorism in the hypochondria. These symptoms, indeed, are constant.

But, if it be near the accession of the paroxysm, there are before the sight circular flashes of purple or black colours, or of all mixed together, so as to exhibit the appearance of the rainbow expanded in the heavens; noises in the ears; a heavy smell; they are passionate, and unreasonably peevish. They fall down then, some from any such cause as lowness of spirits, but others from gazing intently on a running stream, a rolling wheel, or a turning top. But sometimes the smell of heavy odours, such as of the gagate stone ( jet), makes them fall down. In these cases, the ailment is fixed in the head, and from it the disorder springs; but, in others, it arises also from the nerves remote from the head, which sympathise with the primary organ. Wherefore the great fingers of the hands, and the great toes of the feet are contracted; pain, torpor, and trembling succeed, and a rush of them to the head takes place. If the mischief spread until it reach the head, a crash takes place, in these cases, as if from the stroke of a piece of wood, or of stone; and, when they rise up, they tell how they have been maliciously struck by some person. This deception occurs to those who are attacked with the ailment for the first time. But those to whom the affection has become habitual, whenever the disease recurs, and has already seized the finger, or is commencing in any part, having from experience a foreknowledge of what is about to happen, call, from among those who are present, upon their customary assistants, and entreat them to bind, pull aside, and stretch the affected members; and they themselves tear at their own members, as if pulling out the disease; and such assistance has sometimes put off the attack for a day. But, in many cases, there is the dread as of a wild beast rushing upon them, or the phantasy of a shadow; and thus they have fallen down.

In the attack, the person lies insensible; the hands are clasped together by the spasm; the legs not only plaited together, but also dashed about hither and thither by the tendons. The calamity bears a resemblance to slaughtered bulls; the neck bent, the head variously distorted, for sometimes it is arched, as it were, forwards, so that the chin rests upon the breast; and sometimes it is retracted to the back, as if forcibly drawn thither by the hair, when it rests on this shoulder or on that. They gape wide, the mouth is dry; the tongue protrudes, so as to incur the risk of a great wound, or of a piece of it being cut off, should the teeth come forcibly together with the spasm; the eyes rolled inwards, the eyelids for the most part are separated, and affected with palpitation; but should they wish to shut the lids they cannot bring them together, insomuch that the white of the eyes can be seen from below. The eyebrows sometimes relaxed towards the mesal space, as in those who are frowning, and sometimes retracted to the temples abnormally, so that the skin about the forehead is greatly stretched, and the wrinkles in the intersuperciliary space disappear: the cheeks are ruddy and quivering; the lips sometimes compressed together to a sharp point, and sometimes separated towards the sides, when they are stretched over the teeth, like as in persons smiling.

As the illness increases lividity of countenance also supervenes, distension of the vessels in the neck, inability of speech as in suffocation; insensibility even if you call loudly. The utterance a moaning and lamentation; and the respiration a sense of suffocation, as in a person who is throttled; the pulse strong, and quick, and small in the beginning,—great, slow, and feeble in the end, and irregular throughout; tentigo of the genital organs. Such sufferings do they endure towards the end of the attack.

But when they come to the termination of the illness, there are unconscious discharges of the urine, and watery discharges from the bowels, and in some cases an evacuation also of the semen, from the constriction and compression of the vessels, or from the pruriency of the pain, and titillation of the humours; for in these cases the pains are seated in the nerves. The mouth watery; phlegm copious, thick, cold, and, if you should draw it forth, you might drag out a quantity of it in the form of a thread. But, if with length of time and much pain, the matters within the chest ferment, but the restrained spirit ( pneuma) agitates all things, and there is a convulsion and disorder of the same, a flood, as it were, of humours swells up to the organs of respiration, the mouth, and the nose; and if along with the humours the spirit be mixed, it appears like the relief of all the former feelings of suffocation. They accordingly spit out foam, as the sea ejects froth in mighty tempests; and then at length they rise up, the ailment now being at an end. At the termination, they are torpid in their members at first, experience heaviness of the head, and loss of strength, and are languid, pale, spiritless, and dejected, from the suffering and shame of the dreadful malady.

TETANUS, in all its varieties, is a spasm of an exceedingly painful nature, very swift to prove fatal, but neither easy to be removed. They are affections of the muscles and tendons about the jaws; but the illness is communicated to the whole frame, for all parts are affected sympathetically with the primary organs. There are three forms of the convulsion, namely, in a straight line, backwards, and forwards. Tetanus is in a direct line, when the person labouring under the distention is stretched out straight and inflexible. The contractions forwards and backwards have their appellation from the tension and the place; for that backwards we call Opisthotonos; and that variety we call Emprosthotonos in which the patient is bent forwards by the anterior nerves. For the Greek word τόνος is applied both to a nerve, and to signify tension.

The causes of these complaints are many; for some are apt to supervene on the wound of a membrane, or of muscles, or of punctured nerves, when, for the most part, the patients die; for, spasm from a wound is fatal. And women also suffer from this spasm after abortion; and, in this case, they seldom recover. Others are attacked with the spasm owing to a severe blow in the neck. Severe cold also sometimes proves a cause; for this reason, winter of all the seasons most especially engenders these affections; next to it, spring and autumn, but least of all summer, unless when preceded by a wound, or when any strange diseases prevail epidemically. Women are more disposed to tetanus than men, because they are of a cold temperament; but they more readily recover, because they are of a humid. With respect to the different ages, children are frequently affected, but do not often die, because the affection is familiar and akin to them; striplings are less liable to suffer, but more readily die; adults least of all, whereas old men are most subject to the disease, and most apt to die; the cause of this is the frigidity and dryness of old age, and the nature of the death. But if the cold be along with humidity, these spasmodic diseases are more innocent, and attended with less danger.

In all these varieties, then, to speak generally, there is a pain and tension of the tendons and spine, and of the muscles connected with the jaws and cheek; for they fasten the lower jaw to the upper, so that it could not easily be separated even with levers or a wedge. But if one, by forcibly separating the teeth, pour in some liquid, the patients do not drink it but squirt it out, or retain it in the mouth, or it regurgitates by the nostrils; for the isthmus faucium is strongly compressed, and the tonsils being hard and tense, do not coalesce so as to propel that which is swallowed. The face is ruddy, and of mixed colours, the eyes almost immoveable, or are rolled about with difficulty; strong feeling of suffocation; respiration bad, distension of the arms and legs; subsultus of the muscles; the countenance variously distorted; the cheeks and lips tremulous; the jaw quivering, and the teeth rattling, and in certain rare cases even the ears are thus affected. I myself have beheld this and wondered! The urine is retained, so as to induce strong dysuria, or passes spontaneously from contraction of the bladder. These symptoms occur in each variety of the spasms.

But there are peculiarities in each; in Tetanus there is tension in a straight line of the whole body, which is unbent and inflexible; the legs and arms are straight.

Opisthotonos bends the patient backward, like a bow, so that the reflected head is lodged between the shoulder-blades; the throat protrudes; the jaw sometimes gapes, but in some rare cases it is fixed in the upper one; respiration stertorous; the belly and chest prominent, and in these there is usually incontinence of urine; the abdomen stretched, and resonant if tapped; the arms strongly bent back in a state of extension; the legs and thighs are bent together, for the legs are bent in the opposite direction to the hams.

But if they are bent forwards, they are protuberant at the back, the loins being extruded in a line with the back, the whole of the spine being straight; the vertex prone, the head inclining towards the chest; the lower jaw fixed upon the breast bone; the hands clasped together, the lower extremities extended; pains intense; the voice altogether dolorous; they groan, making deep moaning. Should the mischief then seize the chest and the respiratory organs, it readily frees the patient from life; a blessing this, to himself, as being a deliverance from pains, distortion, and deformity; and a contingency less than usual to be lamented by the spectators, were he a son or a father. But should the powers of life still stand out, the respiration, although bad, being still prolonged, the patient is not only bent up into an arch but rolled together like a ball, so that the head rests upon the knees, while the legs and back are bent forwards, so as to convey the impression of the articulation of the knee being dislocated backwards.

An inhuman calamity! an unseemly sight! a spectacle painful even to the beholder! an incurable malady! owing to the distortion, not to be recognised by the dearest friends; and hence the prayer of the spectators, which formerly would have been reckoned not pious, now becomes good, that the patient may depart from life, as being a deliverance from the pains and unseemly evils attendant on it. But neither can the physician, though present and looking on, furnish any assistance, as regards life, relief from pain or from deformity. For if he should wish to straighten the limbs, he can only do so by cutting and breaking those of a living man. With them, then, who are overpowered by the disease, he can merely sympathise. This is the great misfortune of the physician.

ANGINA is indeed a very acute affection, for it is a compression of the respiration. But there are two species of it; for it is either an inflammation of the organs of respiration, or an affection of the spirit ( pneuma) alone, which contains the cause of the disease in itself.

The organs affected are, the tonsils, epiglottis, pharynx, uvula, top of the trachea; and, if the inflammation spread, the tongue also, and internal part of the fauces, when they protrude the tongue outside the teeth, owing to its abnormal size; for it fills the whole of the mouth, and the protuberance thereof extends beyond the teeth. This species is called Cynanche, either from its being a common affection of those animals, or from its being a customary practice for dogs to protrude the tongue even in health.

The opposite symptoms attend the other species; namely, collapse of the organs, and diminution of the natural size, with intense feeling of suffocation, insomuch that it appears to themselves as if the inflammation had disappeared to the internal parts of the thorax, and had seized upon the heart and lungs. This we call Synanche, as if from the disease inclining inwardly and producing suffocation. It appears to me that this is an illness of the spirit ( pneuma) itself, which has under-gone a morbid conversion to a hotter and drier state, without any inflammation of the organ itself. Nor is this any great wonder. For in the Charonæan caves the most sudden suffocations occur from no affection of any organ, ¹ but the persons die from one inspiration, before the body can sustain any injury. But likewise a man will be seized with rabies, from respiring the effluvia of the tongue of a dog, without having been bitten. It is not impossible then, that such a change of the respiration should occur within, since many other phenomena which occur in a man bear a resemblance to external causes, such as juices which become spoiled both within and without. And diseases resemble deleterious substances, and men have similar vomitings from medicines and from fevers. Hence, also, it was not a wonderful thing, that in the plague of Athens, certain persons fancied that poisonous substances had been thrown into the wells in the Piræus by the Peloponnesians; for these persons did not perceive the affinity between a pestilential disease and deleterious substances.

Cases of Cynanche are attended with inflammation of the tonsils, of the fauces, and of the whole mouth; the tongue protrudes beyond the teeth and lips; they have salivation, the phlegm running out very thick and cold; they have their faces ruddy and swollen; their eyes protuberant, wide open, and red; the drink regurgitates by the nostrils. The pains violent, but obscured by the urgency of the suffocation; the chest and heart are in a state of inflammation; there is a longing for cold air, yet they inspire but little, until they are suffocated from the obstruction of the passage to the chest. In certain cases, there is a ready transference of the disease to the chest, and these die from the metastasis; the fevers feeble, slight, bringing no relief. But if, in any case, there is a turn to the better, abscesses form on either side, near the ears externally, or internally about the tonsils; and if these occur with torpor, and are not very protracted, the patients recover, indeed, but with pain and danger. But, if a particularly large swelling should occur, in such cases as are converted to an abscess, and the abscess is raised to a point, they are quickly suffocated. Such are the peculiar symptoms of cynanche.

Those of Synanche are, collapse, tenuity, and paleness; the eyes hollow, sunk inwardly; the fauces and uvula retracted upwards, the tonsils approaching one another still more; loss of speech: the feeling of suffocation is much stronger in this species than in the former, the mischief being seated in the chest whence the source of respiration. In the most acute cases, the patients die the same day, in some instances, even before calling in the physician; and in others, although called in, he could afford them no relief, for they died before the physician could apply the resources of his art. In those in which the disease takes a favourable turn, all the parts become inflamed, the inflammation being determined outwardly, so that the disease becomes cynanche in place of synanche. It is also a good thing when a strong swelling, or erysipelas, appears externally on the chest. And the skilful physician diverts the mischief to the chest by means of the cupping-instrument, or by applying mustard to the breast and the parts near the jaws he determines outwardly and discusses the disease. In certain cases, indeed, the evil by these means has been for a time driven outwards, but when so driven out it speedily reverts, and produces suffocation.

The causes are infinite, more especially exposure to cold, and, less frequently, to heat; blows; fish-bones fixed in the tonsils, cold draughts, intoxication, repletion, and the ills from respiration.

THE solid body suspended from the roof of the mouth between the two tonsils is called columella and gurgulio. Uva is the name of the affection. The columella ( uvula) is of a nervous nature, but humid, for it is situated in a humid region. Wherefore this body, the columella, suffers from various affections, for it becomes thickened from inflammation, being elongated and of equal thickness from the base to the extremity, and is attended with redness. Columna is the appellation of this affection. If it be rounded towards the extremity alone, and with its enlargement become livid and darkish, the name of the affection is Uva; for it altogether resembles a grape in figure, colour, and size. A third affection is that of the membranes when they have the appearance of broad sails, or the wings of bats, on this side and on that. This is called Lorum, for the lengthened folds of the membranes resemble thongs. But if the columella terminates in a slender and elongated membrane, having at its extremity a resemblance to the butt-end of a spear, it gets the name of Fimbria. This affection arises spontaneously from a defluxion, like the others, but also from an oblique incision when the surgeon leaves the membrane at one side. ² But if the organ (uvula) become bifid with two membranes hanging on this side and on that, it has no distinct appellation, but it is an easy matter for any one who sees it to recognise the nature of the disease.

A sense of suffocation accompanies all these affections, and they can by no means swallow with freedom. There is cough in all the varieties, but especially in those named lorum and fimbria. For a titillation of the trachea is produced by the membrane, and in some cases it secretly instils some liquid into the windpipe, whence they cough. But in uva and columella there is still more dyspnœa and very difficult deglutition; for, in these cases, the fluid is squeezed up to the nostrils, from sympathy of the tonsils. The columella is common in old persons, the uva in the young and in adults; for they abound in blood, and are of a more inflammatory nature. The affections of the membranes are common in puberty and infancy. It is safe to apply the knife in all these varieties; but in the uva, while still red, hemorrhage, pains, and increase of inflammation supervene.

ULCERS occur on the tonsils; some, indeed, of an ordinary nature, mild and innocuous; but others of an unusual kind, pestilential, and fatal. Such as are clean, small, superficial, without inflammation and without pain, are mild; but such as are broad, hollow, foul, and covered with a white, livid, or black concretion, are pestilential. Aphtha is the name given to these ulcers. But if the concretion has depth, it is an Eschar and is so called: but around the eschar there is formed a great redness, inflammation, and pain of the veins, as in carbuncle; and small pustules form, at first few in number, but others coming out, they coalesce, and a broad ulcer is produced. And if the disease spread outwardly to the mouth, and reach the columella ( uvula) and divide it asunder, and if it extend to the tongue, the gums, and the alveoli, the teeth also become loosened and black; and the inflammation seizes the neck; and these die within a few days from the inflammation, fever, fœtid smell, and want of food. But, if it spread to the thorax by the windpipe, it occasions death by suffocation within the space of a day. For the lungs and heart can neither endure such smells, nor ulcerations, nor ichorous discharges, but coughs and dyspnœa supervene.

The cause of the mischief in the tonsils is the swallowing of cold, rough, hot, acid, and astringent substances; for these parts minister to the chest as to the purposes of voice and respiration; and to the belly for the conveyance of food; and to the stomach for deglutition. But if any affection occur in the internal parts, namely, the belly, the stomach, or the chest, an ascent of the mischief by the eructations takes place to the isthmus faucium, the tonsils, and the parts there; wherefore children, until puberty, especially suffer, for children in particular have large and cold respiration; for there is most heat in them; moreover, they are intemperate in regard to food, have a longing for varied food and cold drink; and they bawl loud both in anger and in sport; and these diseases are familiar to girls until they have their menstrual purgation. The land of Egypt especially engenders it, the air thereof being dry for respiration, and the food diversified, consisting of roots, herbs of many kinds, acrid seeds, and thick drink; namely, the water of the Nile, and the sort of ale prepared from barley. Syria also, and more especially Cœlosyria, engenders these diseases, and hence they have been named Egyptian and Syrian ulcers.

The manner of death is most piteous; pain sharp and hot as from carbuncle; ³ respiration bad, for their breath smells strongly of putrefaction, as they constantly inhale the same again into their chest; they are in so loathsome a state that they cannot endure the smell of themselves; countenance pale or livid; fever acute, thirst is if from fire, and yet they do not desire drink for fear of the pains it would occasion; for they become sick if it compress the tonsils, or if it return by the nostrils; and if they lie down they rise up again as not being able to endure the recumbent position, and, if they rise up, they are forced in their distress to lie down again; they mostly walk about erect, for in their inability to obtain relief they flee from rest, as if wishing to dispel one pain by another. Inspiration large, as desiring cold air for the purpose of refrigeration, but expiration small, for the ulceration, as if produced by burning, is inflamed by the heat of the respiration. Hoarseness, loss of speech supervene; and these symptoms hurry on from bad to worse, until suddenly falling to the ground they expire.

UNDER the ribs, the spine, and the internal part of the thorax as far as the clavicles, there is stretched a thin strong membrane, adhering to the bones, which is named succingens. When inflammation occurs in it, and there is heat with cough and parti-coloured sputa, the affection is named Pleurisy. But all these symptoms must harmonise and conspire together as all springing from one cause; for such of them as occur separately from different causes, even if they all occur together, are not called pleurisy. It is accompanied by acute pain of the clavicles; heat acrid; decubitus on the inflamed side easy, for thus the membrane ( pleura) remains in its proper seat, but on the opposite side painful; for by its weight, the inflammation and suspension of the membrane, the pain stretches to all its adhesions at the shoulders and clavicles; and in certain cases even to the back and shoulder blade; the ancients called this affection Dorsal pleurisy. It is attended with dyspnœa, insomnolency, anorexia, florid redness of the cheeks, dry cough, difficult expectoration of phlegm, or bilious, or deeply tinged with blood, or yellowish; and these symptoms observe no order, but come and go irregularly; but, worst of all, if the bloody sputa cease, and the patients become delirious; and sometimes they become comatose, and in their somnolency the mind wavers.

But if the disease take a bad turn, all the symptoms getting worse, they die within the seventh day by falling into syncope; or, if the commencement of the expectoration, and the more intense symptoms occurred with the second hebdomad, they die on the fourteenth day. It sometimes happens that in the intermediate period there is a transference of all the symptoms to the lungs; for the lung attracts to itself, being both porous and hot, and being moved for the attraction of the substances around, when the patient is suddenly suffocated by metastasis of the affection. But if the patient pass this period, and do not die within the twentieth day, he becomes affected with empyema. These, then, are the symptoms if the disease get into a bad state.

But if it take a favourable turn, there is a profuse hemorrhage by the nostrils, when the disease is suddenly resolved; then follow sleep and expectoration of phlegm, and afterwards of thin, bilious matters; then of still thinner, and again of bloody, thick, and flesh-like; and if, with the bloody, the bile return, and with it the phlegm, the patient’s convalescence is secure; and these symptoms, if they should commence on the third day, with an easy expectoration of smooth, consistent, liquid, and (not) rounded sputa, the resolution takes place on the seventh day, when, after bilious discharges from the bowels, there is freedom of respiration, the mind settled, fever diminishing, and return of appetite. But if these symptoms commence with the second week, the resolution occurs on the fourteenth day.

But if not so, it is converted into Empyema, as indicated by rigors, pungent pains, the desire of sitting erect, and the respiration becoming worse. It is then to be dreaded, lest, the lungs suddenly attracting the pus, the patient should be thereby suffocated, after having escaped the first and greater evils. But if the abscess creep in between the ribs and separate them, and point outwardly; or, if it burst into an intestine, for the most part the patient recovers.

Among the seasons of the year winter most especially engenders the disease; next, autumn; spring, less frequently; but summer most rarely. With regard to age, old men are most apt to suffer, and most readily escape from an attack; for neither is there apt to be a great inflammation in an arid frame; nor is there a metastasis to the lungs, for old age is more frigid than any other age, and the respiration small, and the attraction of all things deficient. Young men and adults are not, indeed, very apt to suffer attacks; but neither, also, do they readily recover, for from a slight cause they would not experience even a slight attack of inflammation, and from great attacks there is greater danger. Children are least of all liable to pleurisy, and in their case it is less frequently fatal; for their bodies are rare, secretions copious, perspiration and exhalation abundant; hence neither is a great inflammation formed. This is the felicity of their period of life in the present affection.