and which shew a particular determination of the blood to the vessels of the head. These diseases often admit of a solution by this hæmorrhagy, when it may be properly termed critical.

813. The disease sometimes comes on without any previous symptoms; particularly, when some external violence has a share in producing it. But, when it proceeds entirely from an internal cause, it is commonly preceded by headachs, redness of the eyes, a florid colour of the face, an unusual pulsation in the temples, a sense of fulness about the nose, and an itching of the nostrils. A bound belly, pale urine, coldness of the feet, and cold shivering over the whole body, are also sometimes among the symptoms that precede the disease.

814. From the weakness of the vessels of the nose, the blood often flows from them without any considerable effort of the whole system, and therefore without any observable febrile disorder; which, however, in many cases, is, in all its circumstances, very discernible.

815. An hæmorrhagy of the nose happening to young persons, is, and may generally be considered as a slight disease of little consequence, and hardly requiring any remedy. But, even in young persons, when it recurs very frequently, and is very copious, it will require particular attention,

as it is to be considered as a mark of arterial plethora; and, as frequently returning, it may increase the plethoric state; which, in a more advanced stage of life, may give the blood a determination to parts from which the hæmorrhagy would be more dangerous. All this will more particularly require attention, according as the marks of plethora, and of particular congestion, preceding the hæmorrhagy, are more considerable; and as the flowing of the blood is attended with a more considerable degree of febrile disorder.

816. When the epistaxis happens to persons after their acmé, returning frequently, and flowing copiously, it is always to be considered as a dangerous disease, and as more certainly threaten ing the consequences mentioned in the last paragraph.

817. When this hæmorrhagy happens in the decline of life, it may be considered as in itself very salutary but, at the same time, it is to be considered as a mark of a very dangerous state of the system; that is, as a mark of a very strong tendency to a venous plethora in the vessels of the head and I have accordingly observed it often followed by apoplexy, palsy, or such like diseases.

818. When an hæmorrhagy from the nose

happens in febrile diseases, as mentioned in 812, and is in pretty large quantity, it may be considered as critical and salutary; but it is very apt to be profuse, and even in this way dangerous.

It upon some occasions occurs during the eruptive fever of several exanthemata, and is in such cases sometimes salutary; but, if these exanthe mata be accompanied with any putrid tendency, this hæmorrhagy, like artificial blood-lettings, may have very bad effects.

819. Having thus explained the several circumstances of epistaxis, I proceed to consider the management and cure of it. I use the expression of management, because it has been usually thought to require no cure, but that nature should be allowed to throw out blood in this way very frequently; and as often as it appears to arise from internal causes, that is, from a state of the system supposed to require such evacuation.

820. I am however of opinion, for the reasons given in 779, that this disease is very seldom to be left to the conduct of nature; and that in all cases it should be moderated by keeping the patient in cool air; by giving cold drink; by keeping the body and head erect; by avoiding any blowing of the nose, speaking, or other irritation: and, when the blood has flowed for some time, without shewing any tendency to cease, a profuse

bleeding is to be prevented by measures employed to stop it; such as pressing the nostril from which the blood flows, washing the face with cold water, or applying this to other parts of the body.

821. Even in the case of young persons, where the disease is least hazardous, and even in the first attacks, I judge such measures to be proper: but they will be still more proper, if the disease frequently recurs without any external violence; if the returns shall happen to persons of a habit disposed to be plethoric; and, more particularly, if the marks of a plethoric state appear in the precedent symptoms. (813).

822. Even in young persons, if the bleeding be very profuse and long continued, and more especially if the pulse become weak and the face pale, I apprehend it will be proper to suppress the hæmorrhagy by every means in our power. See 797, and following paragraphs.

823. Further, in the same case of young persons, when the returns of this hæmorrhagy be come frequent, and especially with the marks of a plethoric habit, I think it necessary to employ such a regimen as may prevent a plethoric state, (783, 787). At the same time, care should be taken to avoid all circumstances which may determine the blood more fully to the vessels of the head, or

prevent its free return from them; and, by keeping an open belly, to make some derivation from

them.

824. In adult persons, liable to frequent returns of the epistaxis, the whole of the measures proposed 323, are more certainly and freely to be employed. When, with the circumstances mentioned in 813, the tendency to a profuse hæmorrhagy appears, a bleeding at the arm may be proper, even in young persons; but, in the case of adults, it will be still more allowable, and even necessary.

825. In persons of any age liable to frequent returns of this hæmorrhagy, when the measures proposed in 817, et seq. shall have been neglected, or, from peculiar circumstances in the balance of the system, shall have proved ineffectual, and the symptoms threatening hæmorrhagy (838), shall appear, it will then be proper, by blood-letting, cooling purgatives, and every part of the antiphlogistic regimen, to prevent the hæmorrhagy, or at least to prevent its being profuse when it does happen.

826. In the circumstances just now mentioned 825, the measures proposed are proper, and even necessary; but it should at the same time be observed, that these are practised with much less