morasses, contagion from human effluvia, and animal bodies, and that
from specifick unknown origin, I shall make a few observations. Of
what elementary nature miasma and contagion consist; the analysis of
their minute atoms; whether animalculæ, or to us invisible emanations,
I pretend not to decide. Of small pox, measles, scarlet fever, and
sweating sickness, we are totally ignorant of their origin and
essence. We, however, know to a certainty, and it is of infinitely
more importance to the publick safety, that neither marshy miasma,
nor those from human effluvia, spread to any considerable distance
through the air. Even by the plague the atmosphere is tainted to a
very inconsiderable distance; and mankind find an asylum and sanctuary
within a few yards. Nor do marshy miasma emitted from the earth,
mount or diffuse themselves to any considerable distance in the air:
the inhabitants at the top of a hill have continued healthy, whilst
those situated in a swamp at the bottom, have been infested with
intermittents, and remittents. To what distance the contagion of small
pox, measles, and scarlet fever extend through the air, I am ignorant:
like the plague, the two former have been transplanted to distant
regions, in animal bodies, or in polluted porous materials. Another
important discovery of modern times is, that by fire and smoke, the
heat of a baker’s oven, the most virulent contagion may be annihilated,
when concentrated in apparel, spungy materials, ships, houses, &c.
_Of Febrile Prognosticks._ The event of all the preceding fevers
(intermittent excepted) is terminated with precipitancy in a few days,
or, at the utmost, a few weeks in recovery, in death, or in some
other disease. The predictions in fevers, and indeed in all diseases,
should be deduced from the comparative mortality at different ages;
the comparative mortality by different fevers; the symptoms peculiar
to each genus, whether ominous or propitious; and the general symptoms
applicable to an intire group or class. These enrich medicine with
a rudder, compass and quadrant: in them consist the tactick and the
sublime of medical divination. We have already treated of the three
former, and have now only to add the general febrile predictions.
It is foreign to my plan, to squander time or words, in eulogy or
censure of those elaborate treatises on the pulse and urine, and their
presumed extensive application to the diagnostick and prognostick of
diseases. Of strength and weakness, hardness and softness, fulness
and inanition, slowness, celerity, velocity, saliency, intermission,
irregularity, and a few other distinctions of the circulation and
arterial pulsation, we are competent judges; and of the measurement
of velocity to a still greater nicety with the stop-watch. But, with
all due reverence to Galen and his copyists, down to De Bordeu, in
discriminating the multitude and variety, if I may be permitted
the expression, of complicated tones, combinations, divisions,
subdivisions, chromaticks and chords in the arterial vibrations,
we confess the bluntness and incapacity of our tangible organs. We
have still fewer scruples to disclaim that affected sagacity and
alchymistical intuition, of forming auguries from the urine; from
its innumerable shades, intermixtures, pellicles, precipitation, and
sediment. This is, even in our time, one of the decoys in vaticination
to inveigle the ignorant and credulous; the stale manœuvres and
chiromancy of vagabond empiricism and imposture.
A few words will finish our general remarks on the pulse. From
physiology, we know that the whole mass of blood is circulated round
the body from the heart, its lever and center, to the circumference,
and back again, in the space of a few minutes. But in the velocity of
the crimson torrent and arterial pulsation, prodigious variations ensue
from age, sex, constitution, peculiar temperament, climate, season,
food, drink, mental passions, exercise, rest, sleep, waking, health,
different diseases, and different periods of the day. It is therefore,
singly, a precarious sign; and did time permit, there would be no
difficulty in demonstrating the urine to be infinitely more fallible.
From infancy to old age, the velocity of the blood decreases, and is
one half slower: in the adult and middle age, between sixty and eighty
pulsations every minute is the usual natural pace: the febrile pulse is
marked at 96, and is sometimes spurred to 130 or 140; and in infants
sometimes outstrips the divisions of time or accurate mensuration.
All fevers with dangerous symptoms may be termed malignant; but in
general, this term is appropriated to fevers, intermittent, remittent,
nervous, putrid, exanthematous, and also to some of those complicated
with topical inflammation. General prognosticks of danger are indicated
by a concatenation of few or many of the following symptoms, which
may, in some degree, be transposed to the intire febrile class; and to
the phlogistick order not yet surveyed: as the brain, lungs, abdominal
viscera, and organs indispensible to life, much deranged: debility in
the executive and legislative functions; or vital, natural, and animal:
signs of putrefactions.
We shall enumerate the principal of those in detail. The pulse weak,
quick, fluttering, salient, irregular, intermittent, its systole
duplicated, its velocity 130 or 140; tendency to faint or fainting in
an erect posture; cold extremities: the respiration slow, laborious,
quick, cold; all the subsidiary muscles of respiration labouring to
distend the thorax; deep interrupted sighs, hiccup; particular noise
in respiration, as if mucus plugged up the throat and lungs: the
stomach very weak, with nausea, sickness, vomiting, desire of acids;
deglutition difficult, struggling, and with noise; involuntary
excretion of feces and urine; thirst; the tongue, teeth, and lips
foul, and furred with a black gelatinous incrustation; the urine pale,
red, black, fetid; intense burning heat in the abdomen; the belly
tumid and puffed; fetid cadaverous smell and exhalations; clammy
sweats, especially in the breast: the blood if drawn not coagulating:
cutaneous petechiæ, like small bruises in different parts; subcutaneous
effusions; hemorrhages: weakness, confusion, irregularity in the
intellectual functions; the manners different from natural; in the
speech or actions something unusual; loquacity; no sleep; coma or
delirium furious, or low and muttering; in the countenance and eyes
perturbation, agitation, amazement, despondency, despair, anxiety;
attempts to rise out of bed; throwing off the bed-cloaths, incessant
tossing about the bed; forgetfulness, loss of memory, so as not to know
the nearest friend; refusing or exspuating food, drink, or medicines;
moats floating before the eyes, and objects seen as through a cloud;
total inattention to every object; twitching and spasms of the tendons
at the wrist: catching and picking with the hands and fingers at the
bed-cloaths, as if feeling for some object; starting of the muscles,
convulsions; trembling of the hands and tongue when thrust out; supine
posture; inability to support themselves erect or sitting; sliding down
to the foot of the bed: livid nose; collapsed cheeks and temples; sunk
and glazy eyes; dead, ghastly countenance, cold extremities.
It has been asserted by authors, that no certain febrile presages
can be formed before the periodical crisis; but this is antiquated
and erroneous. In tropical climates, the critical days are much more
certain and evident than in northern regions: and as transmitted from
the prognostical Alcoran of Hippocrates, are the 3d or 4th, 5, 7, 9,
11, 14, 17, 20; which amounts to rather more than one half critical,
and the remainder non-critical. On such critical days the event is
generally most decisive, whether salutary or fatal; in the non-critical
it is a temporary respite. Besides, in tropical climates, the moon is
observed to have considerable influence on febrile paroxisms, and
crisis. As to the effect of febrile crisis on the human excretories,
we have been sufficiently explicit. The favourable termination of
fevers is chiefly discovered by cessation of delirium, abatement of
the frequency of the pulse; mild sweats equally diffused; the urine
depositing a sediment freely and copiously; coolness of the skin;
return of natural sleep and appetite; and food recruiting the lost
strength. The storm is then subsided, and the ship arrived at anchor.
* * * * *
The phlogistick group of febrile diseases are now to be reviewed.
The majority of these in their immediate causes and mode of cure,
intimately anastomose; and the principal differences in the symptoms
are to be ascribed to the different organs and parts enraged by
inflammation. These are not like the generality of the preceding
fevers, in which most of the corporeal functions participate: here, in
many cases, one single portion of the human organization is originally
transfixed with pain and commotion; and doomed to bear the brunt of
the hydraulick torrent and inundation. After mature consideration, we
imagined it would occasion less confusion and burthen to the memory,
to detach a few diseases from the phlogistick legion. Inflammation of
the ears, eyes, intestines, kidneys, and bladder, are incorporated
amongst the other diseases by which those various organs are liable
to be invested. I am aware that this does not quadrate with the
stiff etiquette of nosological parade: but, without digressing into
a critical disquisition on this subject, I shall content myself with
simply acknowledging that I am no convert to any of those modern
pedagogues in morbid arrangement and nomenclature. With similar
and intentional omission, I avoid the technical subtilities of
parenchymatous and membranaceous inflammation.
_Inflammation of the Brain._ Phrenitis vera. As a primary disease, it
is very rare in this kingdom. It is much more frequent in tropical and
hot climates: and is the febrile calenture of those scorching regions.
With us it is mostly symptomatick in different fevers: and may either
affect the brain and medullary substance, or its investing membranes:
and in the former case the delirium is said to be mild. Morbid
dissections have proved, that when inflammation was believed to be
present, none could be discovered; and in other cases, that the brain
was inflamed, without expressing the usual symptoms. Of idiopathick
phrenzy, the symptoms are, fever, excruciating and deep seated headach,
restlessness, and want of sleep; intolerance of light and noise, with
acute sensibility and irritability; red, prominent, ferocious eyes;
audacious, and flushed countenance; contracted and languid pulse;
throbbing of the temporal arteries; noise in the ears; change in the
voice; impetuous delirium, and the patient, with difficulty, restrained
in bed; dry parched tongue, but sometimes no complaint of thirst;
costiveness; limpid urine. It is extremely dangerous and precipitate,
terminating in a few days in recovery, death, or some other disease;
and is rarely protracted beyond a week. The favourable crisis is
various: by nasal hemorrhage, sweats, diarrhœa, turbid urine: but on
any irregularity or intemperance, convalescents are prone to relapse.
The predisposing and occasional _causes_ are, warm climate; insolation,
especially with the head uncovered; sudden suppression of the puerperal
lochia; intoxication; violent passions of mind; ambition, anger, grief,
profound contemplation, unremitting study; long deprivation of sleep;
external injuries; erysipelas, or scald head prematurely repelled;
violent exercise; symptomatick.
_Angina:_ cynanche, quinsey; and distinguished into the inflammatory;
and into the putrid, gangrenous, or malignant. The mortality by quinsey
and sore throat, appears in the London bills inconsiderable; and
without discrimination of the inflammatory and putrid. Inflammatory
angina is a general and frequent affliction in both sexes, and
especially in ours and some northern regions. Adults more than infants;
and some individuals more than others, are obnoxious to it: its reign
is in spring and autumn, on the change and vicissitudes of the seasons,
or of heat and cold. In that very different species, the Gangrenous
Angina, the ancient authors are nearly barren of information: some
years this is epidemick and contagious in different parts of our
island; and is much more inimical to childhood and adolescence than to
adults; discharging its venom on schools, and the younger branches of
families.
The principal differences in inflammatory angina are in the parts
affected, and the degrees of inflammation; which may be in one or in
both sides; and variously extended over the mucous membrane of the
fauces, tonsils, velum, uvula, pharynx, and larynx. The usual symptoms
are difficulty and pain in deglutition, and sometimes in respiration;
internal intumescence and redness of the fauces, stiffness of the neck,
and the lower jaw moved with pain; frequent and difficult in excreation
of viscid mucus and saliva, and clamminess of the mouth and throat;
impediment in the distinct articulation of words and speech; noise
and darting pain in the ears; flushed face, prominent eyes; quick,
strong, and hard pulse; anxiety, restlessness; sometimes considerable
contiguous tumor externally; and in violent inflammation, necessity of
an erect posture of the head, to prevent suffocation: the more the
pharynx is affected, deglutition is proportionally interrupted; and
some cannot swallow food or liquids during several days. The crisis is
in a few days, at the utmost in a week or two, by resolution, or by
suppuration; seldom or ever by gangrene. Resolution or discussion is
accompanied with copious excreation and salivation; and frequently with
critical perspiration, sweats, urine. Suppuration may be artificially
discharged, or may spontaneously burst internally or externally. With
judicious and opportune assistance, there is trifling danger. When
fatal, it is by suffocation. The predisposing and occasional _causes_
are cold air inspired cold and moist air: perspiration suddenly
checked, especially on the neck; cold water drank when the body is
heated: epidemical influence of the air and seasons.
Inflammation principally attached to the muscles of the os hyoides,
glottis, larynx, and trachea, is fortunately far less frequent than
the former. In this, the current of air being intercepted, there is
necessarily difficulty and pain in respiration, quick short breathing,
sense of strangulation, great anxiety and restlessness; acute squeaking
or ringing sound of the voice; quick and irregular pulse. Of that
disease, which at least in symptoms has considerable analogy with the
present, and called with us the Croup, we are hereafter to treat. We
may here, however, with propriety, subjoin two other inflammations,
the Angina Parotidea, and the Glossitis. The Angina Parotidea is
often epidemick, but not dangerous. It commences as a glandular tumor
externally, at the articulation of the lower jaw, becoming gradually
more enlarged and unequally diffused, increasing to the fourth day, and
from thence declining: and often is succeeded by swelling of the male
testicles, or of the female breasts. The Glossitis is rarely a primary
disease; but mostly complicated with angina, or venereal salivation.
Its symptoms are obvious; pain and swelling of the tongue; speech and
deglutition exercised with difficulty, headach, restlessness, flow of
saliva. If violent in the extreme, there is danger of suffocation or
starving.
The strong cardinal outlines in the features of Angina Gangrenosa are,
symptoms of nervous and putrid fever, with ulcerations in the tonsils.
Upon these we shall enlarge in their rotine and detail: soreness or
uneasiness in the fauces and throat; stiffness of the neck; headach,
nausea, and vomiting; the fauces and tonsils inflamed, but seldom in
any considerable degree, of a shining crimson colour, with ash-coloured
spots on the tonsils, and sloughs, forming soon into corroding ulcers;
some pain is felt in deglutition; there is sudden prostration of
strength; depression of spirits; anxiety and oppression at the breast;
small, quick, and fluttering pulse; dizziness in the head; slight
delirium, especially at the nocturnal exacerbation; heavy, red, and
watery eyes; the tongue foul at the root; in some the voice hoarse;
and in most the nostrils excoriated by a sharp defluxion; the breath
unusually fetid, and generally the fecal discharge: the external tumor
of the fauces, when visible, which, so far as my experience reaches,
was rarely the case, is edematous, indenting by pressure. In most cases
there is a cutaneous efflorescence overspreading the face, neck, and
other parts of the body, in small points, scarcely eminent, or in
confused and confluent blotches: the period of this eruption and of its
duration varies; and with its recedence there is desquamation of the
cuticle.
This is infinitely more dangerous than the inflammatory angina,
terminating salutary or fatal from the third to the seventh day,
according to the degrees of virulence and medical aid. Alarming
symptoms are, great debility; cutaneous petechiæ; the internal
functions of the brain much deranged; weak, quick, fluttering, and
irregular pulse; livid colour of the ulcers; refusal of drink and
medicine; together with the other inauspicious symptoms enumerated
under febrile prognosticks in general. I have seen not only petechiæ,
but also putrescent hemorrhages from the nose and gums in this disease.
At the crisis there are often fetid stools; but whether critical, or
from the acrid matter swallowed, may be disputed. General sweats and
excreation of the ulcerous sloughs are favourable omens. By the speedy
and judicious assistance of remedies and regimen, very few, compared to
the sick and infected, sink. It is epidemick and contagious: but of
the source or nature of the contagion, we are unacquainted.
_Inflammation of the Lungs and Organs of Respiration_, is a frequent
inflammation in northern climates; and most so in spring, autumn,
and winter; when the body, hydraulick canals, and blood are in a
state of inflammatory diathesis: it generally encounters the robust
vigorous constitution, those of strong muscular fibre, and dense rich
blood; the athletick rustick, manufacturer, and artizan; those in
the prime, and in all the intervals between twenty and the decline
of life: it is very rare in infancy, as in idiopathick disease, and
seldom under puberty, or in old age. It is most universal amongst the
male sex; and in all probability, both more universal and destructive
amongst the necessitous laborious mass of the community. We also read
in authors, of spring pleurisies as no unusual affliction in some
climates considerably nearer to the equator than ours. I apprehend,
that in the London registers the mortality by pulmonick inflammation is
under-rated, and perhaps delegated to imposthume and consumption.
Nosologists have enumerated several extraneous symptoms as
complicated species of pleurisy and peripneumony; such as bilious,
erysipelatous, catarrhal, rheumatick, intercostal, arthritick,
verminous, flatulent, scorbutick, putrid, and malignant: most of
which are merely symptomatick: for neither rheumatick pains in the
intercostal muscles, nor flatulence pent up in the intestines, can
impose on medical discernment as genuine pleurisy. The primary seat of
pulmonick inflammation, whether in the parenchyma or internal viscus,
or in its investing membranes, is not clearly established in medical
diagnosticks; and therefore we comprehend pleurisy and peripneumony
under one genus: in most cases they are complicated; and it is now
doubted whether any pure peripneumony occurs without the pleura also
participating in the affliction. The inflammation confined to the
pleura alone, was described as unaccompanied with expectoration; hence
the distinction of dry and humid species; and in genuine pleurisy the
pain was represented as more acute than in peripneumony.
The symptoms of pulmonick inflammation are fever, darting pungent pain
fixed like a dagger in some part of the chest, the side, breast, or
back; and sometimes shooting to the scapula and clavicle: sometimes
the pain is more dull and obtuse; and its situation oftenest in
the side, about the middle of the ribs, between the sternum and
spine; and commonly confined to one lobe. At the invasion there is
shivering, restlessness, anxiety, succeeded by heat: hot accelerated
laborious respiration; load and oppression at the breast; urgent,
short, and painful cough; and very early in the disease more or
less expectoration, streaked with blood; the pain is exasperated by
inspiration and coughing, and mostly fixed, but sometimes veering or
shifting: the pulse quick, full, hard, and tense, like a stretched
chord; the blood drawn forms a buffy tenacious crust on the coagulum;
the urine is of a florid colour: from the violence of pain, patients
are often unable to lay on either side, but compelled to recline
half-erect on their backs: when the inflammation is violent, or both
pulmonick lobes assailed, there is inexpressible anxiety and struggle
in respiration, florid countenance, prominent eyes; with other
symptoms of obstructed circulation, and return of blood from the head,
and menacing suffocation. In the advanced or dangerous stage of the
disease, the pulse is weak, soft, and irregular. Sometimes there is
nausea of the stomach; and sometimes delirium.
The termination of pulmonick inflammation is by resolution, by
suppuration, by gangrene, by fatal effusion of blood, or exudation
of coagulable lymph into the cellular texture. Favourable symptoms
are, as in anginous excreation, facility in expectoration, without
much exertion or coughing, copious, of due consistence, a little
yellow, white, thick, slightly streaked with blood; the sooner this
is concocted and excreted, the sooner is the crisis; less urgent and
painful cough; freer breathing; abatement in the heat of the body and
velocity of the pulse; general perspiration; deposition of sediment in
the urine; nasal hemorrhage; dispersion of the pain, hitherto fixed
in the thorax, about the shoulders, back, or arms; erysipelas in some
external part; pustular eruption about the breast, neck, and scapulæ;
abscesses in different parts. A crisis, when favourable, always ensues
within seven, or at the utmost fourteen days; and after such crisis,
expectoration may continue copious several days.
Inauspicious symptoms are, the respiration struggling and laborious
in the extreme; dry pertinacious cough; no expectoration, or with
difficulty; suppressed expectoration; obtuse pain, with difficult
respiration; frequent violent cough exasperating the pain; the pain
changing from one side into the other; the pulmonick lobes in both
sides inflamed; the breathing intolerable and suffocating, except in an
erect posture, and even then with laborious anxiety; the face turgid
and florid, or pale, with features of consternation; violent headach;
delirium; remission succeeded by relapse; excessive sweats; dry skin;
weak, soft, and irregular pulse; sudden cessation of pain; grumous
livid expectoration; rattling noise in the thorax, as if plugged up
by phlegm; dejected countenance, squalid sunk eyes; great prostration
of strength; cold clammy partial sweats; limpid urine; florid blood
coughed up, or white and glutinous matter resembling the branches of
blood-vessels. Effusion of blood, and exudation of coagulable lymph
into the pulmonary cellular texture, bronchial vesicles and air-pipes,
is more frequently than gangrene, the cause of suffocation and death.
The occurrence of either is seldom later than fourteen days. There
is also great danger of pulmonick inflammation, persevering beyond
seven or, at the utmost, fourteen days, and without any considerable
remission or signs of resolution, terminating in suppuration; of which
the diagnosticks are hereafter marked. Authors have likewise described
a malignant peripneumony, which seems to be a complication of the
preceding deleterious symptoms, and of putrid fever.