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 elaboratetreatises 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, thisterm 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, andcrisis. 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 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 elaboratetreatises 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, thisterm 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, andcrisis. 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.