Zoonomia Volume Ii Part 20

SPECIES.

1. _Febris sensitiva inirritata._ Sensitive inirritated fever. Typhus gravior. Putrid malignant fever. Jail fever. The immediate cause of this disease is the increase of the sensorial power of sensation, joined with the decrease of the sensorial power of irritation; that is, it consists in the febris sensitiva joined with the febris inirritativa of Cla.s.s I. 2. 1.

1. as the febris sensitiva irritata of the preceding genus consists of the febris sensitiva joined with the febris irritativa of Cla.s.s I. 1. 1. 1. In both which the word irritata, and inirritata, are designed to express more or less irritation than the natural quant.i.ty; and the same when applied to some of the diseases of this genus.

This fever is frequently accompanied with topical inflammation, which is liable, if the arterial strength is not supported, to end in sphacelus; and as mortified parts, such as sloughs of the throat, if they adhere to living parts, soon become putrid from the warmth and moisture of their situation; these fevers have been termed putrid, and have been thought to owe their cause to what is only their consequence. In hot climates this fever is frequently induced by the exhalations of stagnating lakes or marshes, which abound with animal substances; but which in colder countries produce fevers with debility only, as the quartan ague, without inflammation.

The sensitive inirritated, or malignant, fever is also frequently produced by the putrid exhalations and stagnant air in prisons; but perhaps most frequently by contact or near approach of the persons, who have resided in them. These causes of malignant fevers contributed to produce, and to support for a while, the septic and antiseptic theory of them; see Sect.

x.x.xIII. 1. 3. The vibices or bruises, and petechiae or purples, were believed to be owing to the dissolved state of the blood by its incipient putrefaction; but hydrostatical experiments have been made, which shew the sizy blood of the patient in sensitive irritated or inflammatory fever, with strong pulse, is more fluid, while it is warm, than this uncoagulable blood taken in this sensitive inirritated, or malignant fever; from whence it is inferred, that these petechiae, and vibices, are owing to the deficient power of absorption in the terminations of the veins, See Cla.s.s I. 2. 1. 5.

This sensitive inirritated fever, or typhus gravior, is distinguished from the inirritative fever, or typhus mitior, in the early stages of it, by the colour of the skin; which in the latter is paler, with less heat, owing to the less violent action of the capillaries; in this it is higher coloured, and hotter, from the greater energy of the capillary action in the production of new vessels. In the more advanced state petechiae, and the production of contagious matter from inflamed membranes, as the aphthae of the mouth, or ulcers of the throat, distinguishes this fever from the former. Delirium, and dilated pupils of the eyes, are more frequent in nervous fevers; and stupor with deafness more frequent attendants on malignant fevers. See Cla.s.s I. 2. 5. 6.

There is another criterion discernible by the touch of an experienced finger; and that is, the coat of the artery in inflammatory fevers, both those attended with strength of pulsation, and these with weak pulsation, feels harder, or more like a cord; for the coats of the arteries in these fevers are themselves inflamed, and are consequently turgid with blood, and thence are less easily compressed, though their pulsations are nevertheless weak: when the artery is large or full with an inflamed coat, it is called hard; and when small or empty with an inflamed coat, it is called sharp, by many writers.

M. M. The indications of cure consist, 1. In procuring a regurgitation of any offensive material, which may be lodged in the long mouths of the lacteals or lymphatics, or in their tumid glands. 2. To excite the system into necessary action by the repeated exhibition of nutrientia, sorbentia, and incitantia; and to preserve the due evacuation of the bowels. 3. To prevent any unnecessary expenditure of sensorial power. 4. To prevent the formation of ulcers, or to promote the absorption in them, for the purpose of healing them.

1. One ounce of wine of ipecacuanha, or about ten grains of the powder, should be given as an emetic. After a few hours three or four grains of calomel should be given in a little mucilage, or conserve. Where something swallowed into the stomach is the cause of the fever, it is liable to be arrested by the lymphatic glands, as the matter of the small-pox inoculated in the arm is liable to be stopped by the axillary lymphatic gland; in this situation it may continue a day or two, or longer, and may be regurgitated during the operation of an emetic or cathartic into the stomach or bowel, as evidently happens on the exhibition of calomel, as explained in Sect.

XXIX. 7. 2. For this reason an emetic and cathartic, with venesection, if indicated by the hardness and fulness of the pulse, will very frequently remove fevers, if exhibited on the first, second, or even third day.

2. Wine and opium, in small doses repeated frequently, but so that not the least degree of intoxication follows, for in that case a greater degree of debility is produced from the expenditure of sensorial power in unnecessary motions. Many weak patients have been thus stimulated to death. See Sect.

XII. 7. 8. The Peruvian bark should be given also in repeated doses in such quant.i.ty only as may strengthen digestion, not impede it. For these purposes two ounces of wine, or of ale, or cyder, should be given every six hours; and two ounces of decoction of bark, with two drachms of the tincture of bark, and six drops of tincture of opium, should be given also every six hours alternately; that is, each of them four times in twenty-four hours. As much rhubarb as may induce a daily evacuation, should be given to remove the colluvies of indigested materials from the bowels; which might otherwise increase the distress of the patient by the air it gives out in putrefaction, or by producing a diarrhoea by its acrimony; the putridity of the evacuations are in consequence of the total inability of the digestive powers; and their delay in the intestines, to the inactivity of that ca.n.a.l in respect to its peristaltic motions.

The quant.i.ties of wine or beer and opium, and bark, above mentioned, may be increased by degrees, if the patient seems refreshed by them; and if the pulse becomes slower on their exhibition; but this with caution, as I have seen irrecoverable mischief done by greater quant.i.ties both of opium, wine, and bark, in this kind of fever; in which their use is to strengthen the digestion of the weak patient, rather than to stop the paroxysms of fever; but when they are administered in intermittents, much larger quant.i.ties are necessary.

The stimulus of small blisters applied in succession, one every three or four days, when the patient becomes weak, is of great service by strengthening digestion, and by preventing the coldness of the extremities, owing to the sympathy of the skin with the stomach, and of one part of the skin with another.

In respect to nutriment, the patient should be supplied with wine and water, with toasted bread, and sugar or spice in it; or with sago with wine; fresh broth with turnips, cellery, parsley; fruit; new milk. Tea with cream and sugar; bread pudding, with lemon juice and sugar; chicken, fish, or whatever is grateful to the palate of the sick person, in small quant.i.ty repeated frequently; with small beer, cyder and water, or wine and water, for drink, which may be acidulated with acid of vitriol in small quant.i.ties.

3. All unnecessary motions are to be checked, or prevented. Hence horizontal posture, obscure room, silence, cool air. All the parts of the skin, which feel too hot to the hand, should be exposed to a current of cool air, or bathed with cold water, whether there are eruptions on it or not. Wash the patient twice a day with cold vinegar and water, or cold salt and water, or cold water alone, by means of a sponge. If some parts are too cold, as the extremities, while other parts are too hot, as the face or breast, cover the cold parts with flannel, and cool the hot parts by a current of cool air, or bathing them as above.

4. For the healing of ulcers, if in the mouth, solution of alum in water about 40 grains to an ounce, or of blue vitriol in water, one grain or two to an ounce may be used to touch them with three or four times a day. Of these perhaps a solution of alum is to be preferred, as it instantly takes away the stench from ulcers I suppose by combining with the volatile alcali which attends it. For this purpose a solution of alum of an ounce to a pint of water should be frequently injected by means of a syringe into the mouth. If there are ulcers on the external skin, fine powder of bark seven parts, and cerusia in fine powder one part, should be mixed, and applied dry on the sore, and kept on by lint, and a bandage.

As sloughs in the mouth are frequently produced by the previous dryness of the membranes, which line it, this dryness should be prevented by frequently moistening them, which may be effected by injection with a syringe, or by a moist sponge, or lastly in the following manner. Place a gla.s.s of wine and water, or of milk and sugar, on a table by the bedside, a little above the level of the mouth of the patient; then, having previously moistened a long piece of narrow listing, or cloth, or flannel, with the same liquor, leave one end of it in the gla.s.s, and introduce the other into the mouth of the patient; which will thus be supplied with a constant oozing of the fluid through the cloth, which acts as a capillary syphon.

The viscid phlegm, which adheres to the tongue, should be coagulated by some austere acid, as by lemon-juice evaporated to half its quant.i.ty, or by crab-juice; and then it may be sc.r.a.ped off by a knife, or rubbed off by flannel, or a sage leaf dipped in vinegar, or in salt and water.

2. _Erysipelas_, St. Anthony's fire, may be divided into three kinds, which differ in their method of cure, the irritated, the inirritated, and the sensitive erysipelas.

_Erysipelas irritatum_ is attended with increase of irritation besides increase of sensation; that is, with strong, hard, and full pulse, which requires frequent venesection, like other inflammations with arterial strength. It is distinguished from the phlegmonic inflammations of the last genus by its situation on the external habit, and by the redness, heat, and tumour not being distinctly circ.u.mscribed; so that the eye or finger cannot exactly trace the extent of them.

When the external skin is the seat of inflammation, and produces sensitive irritated fever, no collection of matter is formed, as when a phlegmon is situated in the cellular membrane beneath the skin; but the cuticle rises as beneath a blister-plaster, and becomes ruptured; and a yellow material oozes out, and becomes insp.i.s.sated, and lies upon its surface; as is seen in this kind of erysipelas, and in the confluent small-pox; or if the new vessels are reabsorbed the cuticle peels off in scales. This difference of the termination of erysipelatous and phlegmonic inflammation seems to be owing in part to the less distensibility of the cuticle than of the cellular membrane, and in part to the ready exhalation of the thinner parts of the secreted fluids through its pores.

This erysipelas is generally preceded by a fever for two or three days before the eruption, which is liable to appear in some places, as it declines in others; and seems frequently to arise from a previous scratch or injury of the skin; and is attended sometimes with inflammation of the cellular membrane beneath the skin; whence a real phlegmon and collection of matter becomes joined to the erysipelas, and either occasions or increases the irritated fever, which attends it.

There is a greater sympathy between the external skin and the meninges of the brain, than between the cellular membrane and those meninges; whence erysipelas is more liable to be preceded or attended, or succeeded, by delirium than internal phlegmons. I except the mumps, or parot.i.tis, described below; which is properly an external gland, as its excretory duct opens into the air. When pain of the head or delirium precedes the cutaneous eruption of the face, there is some reason to believe, that the primary disease is a torpor of the meninges of the brain; and that the succeeding violent action is transferred to the skin of the face by sensitive a.s.sociation; and that a similar sympathy occurs between some internal membranes and the skin over them, when erysipelas appears on other parts of the body. If this circ.u.mstance should be supported by further evidence, this disease should be removed into Cla.s.s IV. along with the rheumatism and gout. See Cla.s.s IV. 1. 2. 17.

This supposed retropulsion of erysipelas on the brain from the frequent appearance of delirium, has prevented the free use of the lancet early in this disease to the destruction of many; as it has prevented the subduing of the general inflammation, and thus has in the end produced the particular one on the brain. Mr. B----, a delicate gentleman about sixty, had an erysipelas beginning near one ear, and extending by degrees over the whole head, with hard, full, and strong pulse; blood was taken from him four or five times in considerable quant.i.ty, with gentle cathartics, with calomel, diluents, and cool air, and he recovered without any signs of delirium, or inflammation of the meninges of the brain. Mr. W----, a strong corpulent man of inferior life, had erysipelas over his whole head, with strong hard pulse: he was not evacuated early in the disease through the timidity of his apothecary, and died delirious. Mrs. F---- had erysipelas on the face, without either strong or weak pulse; that is, with sensitive fever alone, without superabundance or deficiency of irritation; and recovered without any but natural evacuations. From these three cases of erysipelas on the head it appears, that the evacuations by the lancet must be used with courage, where the degree of inflammation requires it; but not where this degree of inflammation is small, nor in the erysipelas attended with inirritation, as described below.

M. M. Venesection repeated according to the degree of inflammation. An emetic. Calomel three grains every other night. Cool air. Diluents, emetic tartar in small doses, as a quarter of a grain every six hours. Tea, weak broth, gruel, lemonade, neutral salts. See Sect. XII. 6.

Such external applications as carry away the heat of the skin may be of service, as cold water, cold flour, snow, ether. Because these applications impede the exertions of the secerning vessels, which are now in too great action; but any applications of the stimulant kind, as solutions of lead, iron, copper, or of alum, used early in the disease, must be injurious; as they stimulate the secerning vessels, as well as the absorbent vessels, into greater action; exactly as occurs when stimulant eye-waters are used too soon in ophthalmy. See Cla.s.s II. 1. 2. 2. But as the cuticle peels off in this case after the inflammation ceases, it differs from ophthalmy; and stimulant applications are not indicated at all, except where symptoms of gangrene appear. For as a new cuticle is formed under the old one, as under a blister, the serous fluid between them is a defence to the new cuticle, and should dry into a scab by exhalation rather than be reabsorbed. Hence we see how greasy or oily applications, and even how moist ones, are injurious in erysipelas; because they prevent the exhalation of the serous effusion between the old and new cuticle, and thus r.e.t.a.r.d the formation of the latter.

_Erysipelas inirritatum_ differs from the former in its being attended with weak pulse, and other symptoms of sensitive inirritated fever. The feet and legs are particularly liable to this erysipelas, which precedes or attends the sphacelus or mortification of those parts. A great and long coldness first affects the limb, and the erysipelas on the skin seems to occur in consequence of the previous torpor of the interior membranes. As this generally attends old age, it becomes more dangerous in proportion to the age, and also to the habitual intemperance of the patient in respect to the use of fermented or spirituous liquor.

When the former kind, or irritated erysipelas, continues long, the patient becomes so weakened as to be liable to all the symptoms of this inirritated erysipelas; especially where the meninges of the brain are primarily affected. As in that case, after two or three efforts have been made to remove the returning periods of torpor of the meninges to the external skin, those meninges become inflamed themselves, and the patient sinks under the disease; in a manner similar to that in old gouty patients, where the torpor of the liver or stomach is relieved by a.s.sociation of the inflammation of the membranes of the feet, and then of other joints, and lastly the power of a.s.sociation ceasing to act, but the excess of sensation continuing, the liver or stomach remains torpid, or become themselves inflamed, and the patient is destroyed.

M. M. Where there exists a beginning gangrene of the extremities, the Peruvian bark, and wine, and opium, are to be given in large quant.i.ties; so as to strengthen the patient, but not to intoxicate, or to impede his digestion of aliment, as mentioned in the first species of this genus.

Cla.s.s II. 1. 2. 1. But where the brain is inflamed or oppressed, which is known either by delirium, with quick pulse; or by stupor, and slow respiration with slow pulse; other means must be applied. Such as, first, a fomentation on the head with warm water, with or without aromatic herbs, or salt in it, should be continued for an hour or two at a time, and frequently repeated. A blister may also be applied on the head, and the fomentation nevertheless occasionally repeated. Internally very gentle stimulants, as camphor one grain or two in infusion of valerian. Wine and water or small beer, weak broth. An enema. Six grains of rhubarb and one of calomel. Afterwards five drops of tincture of opium, which may be repeated every six hours, if it seems of service. Might the head be bathed for a minute with cold water? or with ether? or vinegar?

_Erysipelas sensitivum_ is a third species, differing only in the kind of fever which attends it, which is simply inflammatory, or sensitive, without either excess of irritation, as in the first variety; or the defect of irritation, as in the second variety: all these kinds of erysipelas are liable to return by periods in some people, who have pa.s.sed the middle of life, as at periods of a lunation, or two lunations, or at the equinoxes.

When these periods of erysipelas happen to women, they seem to supply the place of the receding catamenia; when to men, I have sometimes believed them to be a.s.sociated with a torpor of the liver; as they generally occur in those who have drank vinous spirit excessively, though not approbriously; and that hence they supply the place of periodical piles, or gout, or gutta rosea.

M. M. As the fever requires no management, the disease takes its progress safely, like a moderate paroxysm of the gout; but in this case, as in some of the former, the erysipelas does not appear to be a primary disease, and should perhaps be removed to the Cla.s.s of a.s.sociation.

3. _Tonsillitis._ Inflammation of the tonsils. The uncouth term Cynanche has been used for diseases so dissimilar, that I have divided them into Tonsillitis and Parot.i.tis; and hope to be excused for adding a Greek termination to a Latin word, as one of those languages may justly be considered as a dialect of the other. By tonsillitis the inflammation of the tonsils is princ.i.p.ally to be understood; but as all inflammations generally spread further than the part first affected; so, when the summit of the windpipe is also much inflamed, it may be termed tonsillitis trachealis, or croup. See Cla.s.s I. 1. 3. 4. and II. 1. 2. 4.; and when the summit of the gullet is much inflamed along with the tonsil, it may be called tonsillitis pharyngea, as described in Dr. Cullen's Nosologia, Genus X. p. 92. The inflammation of the tonsils may be divided into three kinds, which require different methods of cure.

_Tonsillitis interna._ Inflammation of the internal tonsil. When the swelling is so considerable as to produce difficulty of breathing, the size of the tonsil should be diminished by cutting it with a proper lancet, which may either give exit to the matter it contains, or may make it less by discharging a part of the blood. This kind of angina is frequently attended with irritated fever besides the sensitive one, which accompanies all inflammation, and sometimes requires venesection. An emetic should be given early in the disease, as by its inducing the retrograde action of the vessels about the fauces during the nausea it occasions, it may eliminate the very cause of the inflammation; which may have been taken up by the absorbents, and still continue in the mouths of the lymphatics or their glands. The patient should then be induced to swallow some aperient liquid, an infusion of senna, so as to induce three or four evacuations. Gargles of all kinds are rather hurtful, as the action of using them is liable to give pain to the inflamed parts; but the patients find great relief from frequently holding warm water in their mouths, and putting it out again, or by syringing warm water into the mouth, as this acts like a warm bath or fomentation to the inflamed part. Lastly, some mild stimulant, as a weak solution of salt and water, or of white vitriol and water, may be used to wash the fauces with in the decline of the disease, to expedite the absorption of the new vessels, if necessary, as recommended in ophthalmy.

_Tonsillitis superficialis._ Inflammation of the surface of the tonsils. As the tonsils and parts in their vicinity are covered with a membrane, which, though exposed to currents of air, is nevertheless constantly kept moist by mucus and saliva, and is liable to diseases of its surface like other mucous membranes, as well as to suppuration of the internal substance of the gland; the inflammation of its surface is succeeded by small elevated pustules with matter in them, which soon disappears, and the parts either readily heal, or ulcers covered with sloughs are left on the surface.

This disease is generally attended with only sensitive fever, and therefore is of no danger, and may be distinguished with great certainty from the dangerous inflammation or gangrene of the tonsils at the height of the small-pox, or scarlet fever, by its not being attended with other symptoms of those diseases. One emetic and a gentle cathartic is generally sufficient; and the frequent swallowing of weak broth, or gruel, both without salt in them, relieves the patient, and absolves the cure. When these tumours of the tonsils frequently return I have sometimes suspected them to originate from the absorption of putrid matter from decaying teeth.

See Cla.s.s I. 2. 3. 21. and II. 2. 2. 1.

_Tonsillitis inirritata._ Inflammation of the tonsils with sensitive inirritated fever is a symptom only of contagious fever, whether attended with scarlet eruption, or with confluent small-pox, or otherwise. The matter of contagion is generally diffused, not dissolved in the air; and as this is breathed over the mucaginous surface of the tonsils, the contagious atoms are liable to be arrested by the tonsil; which therefore becomes the nest of the future disease, like the inflamed circle round the inoculated puncture of the arm in supposit.i.tious small-pox. This swelling is liable to suffocate the patient in small-pox, and to become gangrenous in scarlet fever, and some other contagious fevers, which have been received in this manner. The existence of inflammation of the tonsil previous to the scarlet eruption, as the arm inflames in the inoculated small-pox, and suppurates before the variolous eruption, should be a criterion of the scarlet fever being taken in this manner.

M. M. All the means which strengthen the patient, as in the sensitive inirritated fever, Cla.s.s II. 1. 2. 1. As it is liable to continue a whole lunation or more, great attention should be used to nourish the patient with acidulous and vinous panada, broth with vegetables boiled in it, sugar, cream, beer; all which given frequently will contribute much to moisten, clean, and heal the ulcuscles, or sloughs, of the throat; warm water and wine, or acid of lemon, should be frequently applied to the tonsils by means of a syringe, or by means of a capillary syphon, as described in Cla.s.s II. 1. 3. 1. A slight solution of blue vitriol, as two grains to an ounce, or a solution of sugar of lead of about six grains to an ounce, may be of service; especially the latter, applied to the edges of the sloughs, drop by drop by means of a small gla.s.s tube, or small crow-quill with the end cut off, or by a camel's-hair pencil or sponge; to the end of either of which a drop will conveniently hang by capillary attraction; as solutions of lead evidently impede the progress of erysipelas on the exterior skin, when it is attended with feeble pulse. Yet a solution of alum injected frequently by a syringe is perhaps to be preferred, as it immediately removes the fetor of the breath, which must much injure the patient by its being perpetually received into the lungs by respiration.

4. _Parot.i.tis._ Mumps, or branks, is a contagious inflammation of the parotis and maxillary glands, and has generally been cla.s.sed under the word Cynanche or Angina, to which it bears no a.n.a.logy. It divides itself into two kinds, which differ in the degree of fever which attends them, and in the method of cure.

_Parot.i.tis suppurans._ The suppurating mumps is to be distinguished by the acuteness of the pain, and the sensitive, irritated, or inflammatory fever, which attends it.

M. M. Venesection. Cathartic with calomel three or four grains repeatedly.

Cool air, diluents. This antiphlogistic treatment is to be continued no longer than is necessary to relieve the violence of the pain, as the disease is attended with contagion, and must run through a certain time, like other fevers with contagion.

_Parot.i.tis mutabilis._ Mutable parot.i.tis. A sensitive fever only, or a sensitive irritated fever, generally attends this kind. And when the tumor of the parotis and maxillary glands subsides, a new swelling occurs in some distant part of the system; as happens to the hands and feet, at the commencement of the secondary fever of the small-pox, when the tumor of the face subsides. This new swelling in the parot.i.tis mutabilis is liable to affect the testes in men, and form a painful tumor, which should be prevented from suppuration by very cautious means, if the violence of the pain threaten such a termination; as by bathing the part with coldish water for a time, venesection, a cathartic; or by a blister on the perinaeum, or s.c.r.o.t.u.m, or a poultice.

When women are affected with this complaint, after the swelling of the parotis and maxillary glands subsides, a tumor with pain is liable to affect their b.r.e.a.s.t.s; which, however, I have never seen terminate in suppuration.

On the retrocession of the tumor of the testes above described, and I suppose of that of the b.r.e.a.s.t.s in women, a delirium of the calm kind is very liable to occur; which in some cases has been the first symptom which has alarmed the friends of the patient; and it has thence been difficult to discover the cause of it without much inquiry; the previous symptoms having been so slight as not to have occasioned any complaints. In this delirium, if the pulse will bear it, venesection should be used, and three or four grains of calomel, with fomentation of the head with warm water for an hour together every three or four hours.

Though this disease generally terminates favourably, considering the numbers attacked by it, when it is epidemic, yet it is dangerous at other times in every part of its progress. Sometimes the parotis or maxillary glands suppurate, producing ulcers which are difficult to cure, and frequently destroy the patient, where there was a previous scrophulous tendency. The testis in men is also liable to suppurate with great pain, long confinement, and much danger; and lastly the affection of the brain is fatal to many.

Mr. W. W. had a swelled throat, which after a few days subsided. He became delirious or stupid, in which state he was dying when I saw him; and his friends ascribed his death to a coup de soleil, which he was said to have received some months before, when he was abroad.

Mr. A. B. had a swelling of the throat, which after a few days subsided.

When I saw him he had great stupor, with slow breathing, and partial delirium. On fomenting his head with warm water for an hour these symptoms of stupor were greatly lessened, and his oppressed breathing gradually ceased, and he recovered in one day.

Mr. C. D. I found walking about the house in a calm delirium without stupor; and not without much inquiry of his friends could get the previous history of the disease; which had been attended with parot.i.tis, and swelled testis, previous to the delirium. A few ounces of blood were taken away, a gentle cathartic was directed, and his head fomented with warm water for an hour, with a small blister on the back, and he recovered in two or three days.

Mr. D. D. came down from London in the coach alone, so that no previous history could be obtained. He was walking about the house in a calm delirium, but could give no sensible answers to any thing which was proposed to him. His pulse was weak and quick. Cordials, a blister, the bark, were in vain exhibited, and he died in two or three days.