9.Fistula lacrymalis.The lacrymal sack, with its puncta lacrymalia and nasal duct, are liable to be destroyed by suppuration without fever; the tears then run over the eyelids, and inflame the edges of them, and the cheeks, by their perpetual moisture, and saline acrimony.
M. M. By a nice surgical operation a new aperture is to be made from the internal corner of the eye into the nostril, and a silver tube introduced, which supplies the defect by admitting the tears to pass again into the nostril. See Melanges de Chirurgie par M. Pouteau; who thinks he has improved this operation.
10.Fistula in ano.A mucous discharge from the anus, called by some white piles, or matter from a suppurated pile, has been mistaken for the matter from a concealed fistula. A bit of cotton wool applied to the fundament to receive the matter, and renewed twice a day for a week or two, should always be used before examination with the probe. The probe of an unskilful empyric sometimes does more harm in the loose cellular membrane of these parts than the original ulcer, by making a fistula he did not find. The cure of a fistula in ano of those, who have been much addicted to drinking spirituous liquor, or who have a tendency to pulmonary consumption, is frequently of dangerous consequence, and is succeeded by ulcers of the lungs, and death.
M. M. Ward's paste, or 20 black pepper-corns taken after each meal twice a day; the pepper-corns should be cut each into two or three pieces. The late Dr. Monro of Edinburgh asserted in his lectures, that he had known a fistula in ano cured by injecting first a mixture of rectified spirit of wine and water; and by gradually increasing the strength of it, till the patient could bear rectified spirit alone; by the daily use of which at length the sides of the fistula became callous, and ceased to discharge, though the cavity was left. A French surgeon has lately affirmed, that a wire of lead put in at the external opening of the ulcer, and brought through the rectum, and twisted together, will gradually wear itself through the gut, and thus effect a cure without much pain. The ends of the leaden wire must be twisted more and more as it becomes loose. Or, lastly, it must be laid open by the knife.
11.Fistula urethræ.Where a stricture of the urethra exists, from whatever cause, the patient, in forcing the stream of urine through the structure, distends the urethra behind it; which after a time is liable to burst, and to become perforated; and some of the urine is pushed into the cellular membrane, occasioning fistulas, which sometimes have large surfaces producing much matter, which is pressed out at the time of making water, and has been mistaken for a catarrh of the bladder; these fistulas sometimes acquire an external opening in the perinæum, and part of the urine is discharged that way.
Can this matter be distinguished from mucus of the bladder by the criterion delivered in ClassII. 1. 6. 6?
M. M. The perpetual use of bougies, either of catgut or ofcaoutchouc. The latter may be had at No. 37, Red-lion street, Holborn, London. The former are easily made, by moistening the catgut, and keeping it stretched till dry, and then rounding one end with a pen-knife. The use of a warm bath every day for near an hour, at the heat of 94 or 96 degrees, for two or three months, I knew to be uncommonly successful in one case; the extensive fistulas completely healing. The patient should introduce a bougie always before he makes water, and endeavour to make it as slowly as possible. See ClassI. 2. 3. 24.
12.Hepatitis chronica.Chronical inflammation of the liver. A collection of matter in the liver has frequently been found on dissection, which was not suspected in the living subject. Though there may have been no certain signs of such a collection of matter, owing to the insensibility of the internal parts of this viscus; which has thus neither been attended with pain, nor induced any fever; yet there may be in some cases reason to suspect the existence of such an abscess; either from a sense of fulness in the right hypochondre, or from transient pains sometimes felt there, or from pain on pressure, or from lying on the left side, and sometimes from a degree of sensitive fever attending it.
Dr. Saunders suspects the acute hepatitis to exist in the inflammation of the hepatic artery, and the chronical one in that of the vena portarum. Treatise on the Liver. Robinson. London.
13.Scrophula suppurans.Suppurating scrophula. The indolent tumors of the lymphatic glands are liable, after a long time, to regain their sensibility; and then, owing to their former torpor, an increased action of the vessels, beyond what is natural, with inflammation, is the consequence of their new life, and suppuration succeeds. This cure of scrophula generally happens about puberty, when a new energy pervades the whole system, and unfolds the glands and organs of reproduction.
M. M. See ClassI. 2. 3. 21. Where scrophulous ulcers about the neck are difficult to heal, Dr. Beddoes was informed, in Ireland, that an empyric had had some success by inflaming them by an application of wood sorrel, oxalis acetosella, the leaves of which are bruised in a mortar, and applied on the ulcers for two or three days, and then some more lenient application is used.
A poor boy, about twelve years old, had a large scrophulous ulcer on one side of the chest beneath the clavicle, and another under his jaw; he was directed, about three weeks ago, to procure a pound of dry oak-bark from the tanners, and to reduce it to fine powder, and to add to it one ounce of white lead in fine powder, and to cover the ulcers daily with it, keeping it on by brown paper and a bandage. He came to me a few minutes ago, to shew me that both the ulcers are quite healed. The constant application of linen rags, moistened with a solution of an ounce of sugar of lead in a pint of water, I think I have seen equally efficacious.
14.Scorbutus suppurans.In the sea-scurvy there exists an inactivity of venous absorption, whence vibices and petechiæ, and sometimes ulcers. As the column of blood pressing on the of origins of the veins of the lower extremities, when the body is erect, opposes the ascent of the blood in them, they are more frequently liable to become enlarged, and to produce varixes, or vibices, or, lastly, ulcers about the legs, than on the upper parts of the body. The exposure to cold is believed to be another cause of ulcers on the extremities; as happens to many of the poor in winter at Lisbon, who sleep in the open air, without stockings, on the steps of their churches or palaces. See ClassI. 2. 1. 15.
M. M. A bandage spread with plaster to cover the whole limb tight. Rags dipped in a solution of sugar of lead. A warm flannel stocking or roller. White lead and oak bark, both in fine powder. Horizontal rest.
15.Scirrhus suppurans.When a scirrhus affects any gland of no great extent or sensibility, it is, after a long period of time, liable to suppurate without inducing fever, like the indolent tumors of the conglobate or lymphatic glands above mentioned; whence collections of matter are often found after death both in men and other animals; as in the liver of swine, which have been fed with the grounds of fermented mixtures in the distilleries. Another termination of scirrhus is in cancer, as described below. See ClassI. 2. 3. 22.
16.Carcinoma.Cancer. When a schirrous tumor regains its sensibility by nature, or by any accidental hurt, new vessels shoot amongst the yet insensible parts of it, and a new secretion takes place of a very injurious material. This cancerous matter is absorbed, and induces swelling of the neighbouring lymphatic glands; which also become schirrous, and afterwards cancerous.
This cancerous matter does not seem to acquire its malignant or contagious quality, till the cancer becomes an open ulcer; and the matter secreted in it is thus exposed to the air. Then it evidently becomes contagious, because it not only produces hectic fever, like common matter in ulcers open to the air; but it also, as it becomes absorbed, swells the lymphatic glands in its vicinity; as those of the axilla, when the open cancer is on the breast. See ClassII. 1. 3.
Hence exsection before the cancer is open is generally a cure; but after the matter has been exposed to the air, it is seldom of service; as the neighbouring lymphatic glands are already infected. I have observed some of these patients after the operation to have had diseased livers, which might either have previously existed, or have been produced by the fear or anxiety attending the operation.
Erosion with arsenic, after the cancer is become an open ulcer, has generally no better effect than exsection, but has been successful before ulceration. The best manner of using arsenic, is by mixing one grain with a dram of lapis calaminaris, and strewing on the cancer some of the powder every day, till the whole is destroyed.
Cancers on the face are said to arise from the periosteum, and that unless this be destroyed by the knife, or by caustics, the cancer certainly recurs. After the cancer becomes an open ulcer of some extent, a purulent fever supervenes, as from other open ulcers, and gradually destroys the patient. See ClassII. 1. 6. 13.
Two very interesting cases have been lately published by Dr. Ewart, of Bath, in which carbonic acid gas, or fixed air, was kept constantly in contact with the open cancerous ulcers of the breast; which then healed like other common ulcers. This is rather to be ascribed to the exclusion of oxygen, than to any specific virtue in the carbonic acid. As in common ulcers the matter does not induce hectic fever, till it has been exposed to the air, and then probably united with oxygen.
The manner of applying the fixed air, is by including the cancer in one half or hemisphere of a large bladder; the edges are made to adhere to the skin by adhesive plaster, or perhaps a mixture of one part of honey with about twenty parts of carpenter's glue might better suit some tender skins. The bladder is then kept constantly filled with carbonic acid gas, by means of a pipe in the neck of it; and the matter let out at a small aperture beneath.
17.Arthrocele.Swelling of the joints seems to have its remote cause in the softness of the bones, for they could not swell unless they were previously softened, see ClassI. 2. 2. 14. The epiphyses, or ends of the bones, being naturally of a looser texture, are most liable to this disease, and perhaps the cartilages and capsular ligaments may also become inflamed and swelled along with the heads of the bones. This malady is liable to distort the fingers and knees, and is usually called gout or rheumatism; the former of which is liable to disable the fingers by chalk-stones, and thence to have somewhat a similar appearance. But the arthrocele, or swelling of the joints, affects people who have not been intemperate in the use of fermented or spirituous liquors; or who have not previously had a regular gout in their feet; and in both these circumstances differs from the gout. Nor does it accord with the inflammatory rheumatism, as it is not attended with fever, and because the tumors of the joints never entirely subside. The pain or sensibility, which the bones acquire, when they are inflamed, may be owing to the new vessels, which shoot in them in their soft state, as well as to the distention of the old ones.
M. M. Half a grain of opium twice a day, gradually increased to a grain, but not further, for many months. Thirty grains of powder of bark twice a day for many months. Ten grains of bone-ashes, or calcined hartshorn, twice a day, with decoction of madder? Soda phosphorata?
18.Arthropuosis.Joint-evil. This differs from the former, as that never suppurates; these ulcers of the joints are generally esteemed to arise from scrophula; but as scrophula is a disease of the lymphatic or absorbent system, and this consists in the suppuration of the membranes, or glands, or cartilages about the joints, there does not seem a sufficient analogy to authorize their arrangement under the same name.
The white swelling of the knee, when it suppurates, comes under this species, with variety of other ulcers attended with carious bones.
19.Caries ossium.A caries of the bones may be termed a suppuration of them; it differs from the above, as it generally is occasioned by some external injury, as in decaying teeth; or by venereal virus, as in nodes on the tibia; or by other matter derived to the bone in malignant fevers; and is not confined to the ends of them.
The separation of the dead bone from the living is a work of some time. See Sect. XXXIII. 3. 1.
The ulcers, or eruptions, which are formed on the external skin, or on the mouth or throat, or on the air-cells of the lungs, or on the intestines, all of which are more or less exposed to the contact of the atmospheric air, which we breathe, and which in some proportion we swallow with our food and saliva; or to the contact of the inflammable air, or hydrogen, which is set at liberty by the putrefying aliment in the intestines, or by putrefying matter in large abscesses; all of them produce contagious matter; which, on being inoculated into the skin of another person, will produce fever, or a similar disease.
In some cases even the matter formed beneath the skin becomes in some degree contagious, at least so much so as to produce fever of the hectic or malignant kind, as soon as it has pierced through the skin, and has thus gained access to some kind of air; as the fresh puss of a common abscess; or the putrid pus of an abscess, which has been long confined; or of cancerous ulcers.
From this analogy there is reason to suspect, that the matter of all contagious diseases, whether with or without fever, is not infectious till it has acquired something from the air; which, by oxygenating the secreted matter, may probably produce a new acid. And secondly, that in hectic fever a part of the purulent matter is absorbed; or acts on the surface of the ulcer; as variolous matter affects the inoculated part of the arm. And that hectic fever is therefore caused by the matter of an open ulcer; and not by the sensation in the ulcer independent of the aerated pus, which lies on it. Which may account for the venereal matter from buboes not giving the infection, according to the experiments of the late Mr. Hunter, and for some other phenomena of contagion. See Variola discreta, ClassII. 1. 3. 9.
1.Gonorrhœa venerea.A pus-like contagious material discharged from the urethra after impure cohabitation, with smarting or heat on making water; which begins at the external extremity of the urethra, to which the contagious matter is applied, and where it has access to the air.
M. M. In this state of the venereal disease once venesection, with mild cathartics of senna and manna, with mucilage, as almond emulsion, and gum arabic, taken for two or three weeks, absolve the cure. Is camphor of use to relieve the ardor urinæ? Do balsams increase or lessen the heat of urine? Neutral salts certainly increase the smarting in making water, by increasing the acrimony of the urine.
Can the discharge from the urethra be soon stopped by saturnine injections, or mercurial ones, or with solution of blue vitriol, at first very dilute, and gradually made stronger? And at the same time lest the syphilis, or general disease, should supervene, the patient might take a quarter of a grain of corrosive sublimate of mercury twice a day, as directed below?
2.Syphilis.Venereal disease. The contagion shews itself in ulcers on the part first inoculated, as chancres; ulcers on the tonsils succeed, with eruption on the skin, especially about the roots of the hair; afterwards on other parts of the skin, terminating in dry scabs; and lastly, with pain and swelling of the bones.
The corona veneris, or crown of Venus, consists of the eruptions at the roots of the hair appearing most round the forehead; which is occasioned by this part being more exposed to the air; which we observed, at the beginning of this genus, either produces or increases the virulence of contagious matter. But it is difficult to conceive from this history, why the throat should be first affected; as it cannot be supposed, that the disease is so often taken by the saliva, like the small-pox, though this may sometimes occur, perhaps very often. The connection between the genitals in men and the throat, is treated of in ClassIV. 1. 2. 7. Hydrophobia.
M. M. A quarter of a grain of corrosive sublimate of mercury, taken thrice a day for five or six weeks, made into a pill with breadcrumbs, or dissolved in a spoonful of brandy and water, is a very efficacious and almost certain cure. When it does not succeed, it is owing either to the drug being bad, or to its having precipitated from the brandy, or from its being spoiled in the pill by long keeping. Opium contributes much to expedite the cure both of the simple gonorrhœa, and of venereal ulcers, by increasing absorption both from the mucous membrane, and from the surface of ulcers.
3.Lepra.Leprosy. Leprosy of the Greeks. The skin is rough with white branny scales, which are full of chinks; often moist beneath, and itching. The scales on the head or arms of some drinking people are a disease of this kind. The perspirable matter designed for the purpose of lubricating the external skin is secreted in this disease in a too viscid state, owing to the inflammation of the subcutaneous vessels; and, as the absorbents act too strongly at the same time, a viscid mucus is left adhering to the surface of the skin.
In the leprosy of the Jews, described in the thirteenth and fourteenth chapters of Leviticus, the depression of the sore beneath the surface of the skin, and the hairs in it becoming white, seem to have been the principal circumstances, which the priest was directed to attend to for the purpose of ascertaining the disease.
M. M. Essence of antimony from 20 drops to 100 twice or thrice a day, with half a pint of decoction of elm-bark; or tincture of cantharides from 20 to 60 drops four times a day; or sublimate of mercury, with much diluting fluid. Acid of vitriol? Perhaps the cure chiefly depends on much dilution with water, from two to four pints a day, in which elm-bark, or pine-buds, or juniper-tops, may be boiled. Bath or Buxton water drank in large quantities. Warm bath. Oil-skin bound on the part to confine the perspirable matter. Ointment of tar and suet; or poultice for two or three days, and then cerate with lapis calaminaris. Diet of raisins and bread. Abstinence from wine, beer, and all spirits.
4.Elephantiasis.Leprosy of the Arabs. A contagious disease; the skin is thickened, wrinkled, rough, unctuous, destitute of hair, without any sensation of touch in the extremities of the limbs; the face deformed with tubercles; the voice hoarse, and with a nasal tone. Cullen.
5.Framboesia.Yaws is said to be contagious and hereditary. It principally affects the negroes in the West Indies. Edinb. Essays, Vol. VI.
6.Psora.Itch. A contagious prurient eruption. There are two kinds of itch, that which appears between the fingers, and under the joints of the knees and elbows; and that which seldom is seen in these places, but all over the other parts of the body. The latter is seldom thought to be the itch, as it does not easily infect even a bedfellow, and resists the usual means of cure by brimstone.
If the itch be cured too hastily by rubbing mercurial or arsenical preparations over the whole body, or on too great a part of it, many bad symptoms are produced; as weakness of digestion, with pale bloated countenance, and tendency to dropsy. I have twice seen St. Vitus's dance occur from the use of a mercurial girdle; and once a swelled liver. I have also seen a swelled spleen and swelled legs from the external use of arsenic in the cure of the itch. And very numerous and large phlegmons commonly succeed the too hasty cure of it by other means.
There does not appear a strict analogy between the hasty cure of the itch, and the retrocession of the pustles in the secondary fever of the small-pox; because in that the absorption of the matter is evinced by the swelling of the face and hands, as the pustles recede, as explained in ClassII. 1. 3. 9. Variola discreta. And a fever is produced by this absorption; neither of which happen, when the pustles of the itch are destroyed by mercury or arsenic.
Nor can these inconveniences, which occur on the too hasty cure of the itch, be explained by those which follow the cure of some kinds of gutta rosea, ClassII. 1. 4. 6. as in those the eruptions on the face were an associated disease with inflammation of the liver or stomach, which they were accustomed to relieve; whereas the itch is not known to have had any previous catenation with other diseases.
In the itch there exists not only great irritation in the production of the pustles, but great sensation is caused by their acrimony afterwards; insomuch that the pain of itching, without the interrupted smarting occasioned by scratching, would be intolerable. This great excitement of the two sensorial powers of irritation and sensation is so great, when the pustles are diffused over the whole surface of the body, that a torpor succeeds the sudden ceasing of it; which affects those parts of the system, which were most catenated with the new motions of the skin, as the stomach, whence indigestion and flatulency; or which are generally most liable to fall into torpor, as the numerous glands, which form the liver. Whence the diseases consequent to the hasty cure of the itch are diseases of debility, as tumid viscera, œdematous swellings, and St. Vitus's dance, which is a debility of association. In the same manner indigestion, with green evacuations, are said to follow an injudicious application of cerussa to stop too hastily the exsudation behind the ears of children, ClassI. 1. 2. 9. And dropsies are liable to succeed the cure of old ulcers of the legs, which have long stimulated the system.
M. M. The size of a large pea, of an ointment consisting of one part of white precipitate of mercury to six parts of hogs' lard well triturated together, to be rubbed on a part of the body every night, and washed off with soap and water next morning, till every part is cleared; with lac sulphuris twenty grains to be taken every morning inwardly. Warm saline bath, with white vitriol in it. Flowers of sulphur mixed with thick gruel, with hogs fat. With either of which the body may be smeared all over.
7.Psora ebriorum.Elderly people, who have been much addicted to spirituous drinks, as beer, wine, or alcohol, are liable to an eruption all over their bodies; which is attended with very afflicting itching, and which they probably propagate from one part of their bodies to another with their own nails by scratching themselves. I saw fatal effects in one such patient, by a too extensive use of a solution of lead; the eruption disappeared, he became dropsical, and died; I suppose from the too suddenly ceasing of the great stimulus caused by the eruptions over the whole skin, as in the preceding article.
M. M. The patient should gradually accustom himself to half his usual quantity of vinous potation. The warm bath, with one pound of salt to every three gallons. Mercurial ointments on small parts of the skin at a time. A grain of opium at night instead of the usual potation of wine or beer.
8.Herpes.Herpes consists of gregarious spreading excoriations, which are succeeded by branny scales or scabs. In this disease there appears to be a deficient absorption of the subcutaneous mucus, as well as inflammation and increased secretion of it. For the fluid not only excoriates the parts in its vicinity by its acrimony, but is very saline to the taste, as some of these patients have assured me; I believe this kind of eruption, as well as the tinea, and perhaps all other cutaneous eruption, is liable to be inoculated in other parts of the body by the finger-nails of the patients in scratching themselves.
It is liable to affect the hands, and to return at distant periods; and is probably a secondary disease, as well as the zona ignea, or shingles, described below.
M. M. Poultice the eruption with bread and milk, or raw carrots grated, for two or three whole days, to dilute or receive the discharged fluid, and abate the inflammation; then cover the parts with fresh cerate mixed with lapis calaminaris. On the parts not excoriated mercurial ointment, made of one part of white calx of mercury and six of hogs' fat. Internally, after venesection, gentle repeated cathartics. Lastly, the bark. Acid of vitriol. Bolus Armeniæ, or testacia. Antimonials. Decoction of interior bark of elm.
9.Zona ignea.Shingles. This eruption has been thought a species of herpes by some writers, and by others a species of erysipelas. Yellow or livid vesicles appear, producing a corrosive ichor, which is sometimes attended with a degree of fever. It is said to infest sometimes the thorax and ribs, but its most general situation is on the small of the back, over one kidney, extending forward over the course of one of the ureters.
There is reason to suspect, that this also is a secondary or sympathetic disease, as well as the preceding one; but future observations are required, before it can be removed to the fourth class, or diseases of association. In three patients I have been induced to believe, that the eruption on the loins was a translation of inflammation from the external membrane of the kidney to the skin. They had, for a day or two before the appearance of the eruption, complained of a dull pain on the region of one kidney, but without vomiting; by which it was distinguished from nephritis interna, or gravel; and without pain down the outside of the thigh, by which it was distinguished from sciatica. In other situations the shingles may sympathize with other internal membranes, as in a case published by Dr. Russel (De Tabe Glandulari), where the retrocession of the shingles was succeeded by a serious dyspnæa.
M. M. Venesection, if the pulse is strong. Calomel three or four grains, very mild repeated cathartics. Poultice for a few days, then cerate of lapis calaminaris, as in herpes. A grain of emetic tartar dissolved in a pint of water, and taken so as to empty the stomach and intestines, is said much to hasten the cure; compresses soaked in a saturnine solution are recommended externally on the eruption; and cerate where there are ulcerations. Desanet's Surgical Journal, Vol. II. p. 378. If this be a vicarious disease, it should continue half a lunation; lest, on its ceasing, the bad habits of motion of the primary disease should not have been so perfectly dissevered, but that they may recur.
10.Annulus repens.Ring-worm. A prurient eruption formed in a circle, affecting children, and would seem to be the work of insects, according to the theory of Linnæus, who ascribes the itch and dysentery to microscopic animalcula. These animalcula are probably the effect, and not the cause, of these eruptions; as they are to be seen in all putrescent animal fluids. The annular propagation of the ring-worm, and its continuing to enlarge its periphery, is well accounted for by the acrimony of the ichor or saline fluid eroding the skin in its vicinity.
M. M. Cover the eruption daily with ink. With white mercurial ointment, as described above in herpes. With solution of white vitriol ten grains to an ounce. These metallic calces stimulate the absorbents into stronger action, whence the fluid has its saline part reabsorbed, and that before it has access to the air, which probably adds to its acrimony by oxygenating it, and thus, producing a new acid.
11.Tinea.Scald head. This contagious eruption affects the roots of the hair, and is generally most virulent around the edges of the hair on the back part of the head; as the corona veneris appears most on the edges of the hair on the forepart of the head; for in these parts the eruption about the roots of the hair is most exposed to the external air, by which its acrimony or noxious quality is increased.
The absorption of the matter thus oxygenated swells the lymphatics of the neck by its stimulus, occasioning many little hard lumps beneath the seat of the eruption; when this happens, the sooner it is cured the better, lest the larger lymphatics of the neck should become affected.
M. M. The art of curing these eruptions consists, first, in abating the inflammation, and consequent secretion of a noxious material. Secondly, to prevent its access to the air, which so much increases its acrimony. And thirdly, to promote the absorption of it, before it has been exposed to the air; for these purposes venesection once, and gentle cathartics, which promote absorption by emptying the blood-vessels. Next poultices and fomentations, with warm water, abate inflammation by diluting the saline acrimony of the secreted fluid, and abating the painful sensation. Afterwards cerate joined with some metallic calx, as of zinc or lead, or solution of lead, mercury, or copper, or iron, which may stimulate the absorbent system into stronger action.
Cover the shaved head with tar and suet, and a bladder; this, by keeping the air from the secreted fluid, much contributes to its mildness, and the stimulus of the tar increases its absorption. See the three preceding species of this genus.
12.Crusta lactea.Milk-crust is a milder disease than tinea, affecting the face as well as the hairy scalp of very young children. It is not infectious, nor liable to swell the lymphatics in its vicinity like the tinea.
M. M. Cover the eruption with cerate made with lapis calaminaris, to be renewed every day. Mix one grain of emetic tartar with forty grains of chalk, and divide into eight papers, one to be taken twice a day, or with magnesia alba, if stools are wanted. The child should be kept cool and much in the air.
13.Trichoma.Plica polonica. A contagious disease, in which the hair is said to become alive and bleed, forming inextricable knots or plaits of great length, like the fabled head of Medusa, with intolerable pain, so as to confine the sufferer on his bed for years.
1.Febris sensitiva.Sensitive fever, when unmixed with either irritative or inirritative fever, may be distinguished from either of them by the less comparative diminution of muscular strength; or in other words, from its being attended with less diminution of the sensorial power of irritation. An example of unmixed sensitive fever may generally be taken from the pulmonary consumption; in this disease patients are seen to walk about with ease, and to do all the common offices of life for weeks, and even months, with a pulse of 120 strokes in a minute; while in other fevers, whether irritated or inirritated, with a pulse of this frequency, the patient generally lies upon the bed, and exerts no muscular efforts without difficulty.
The cause of this curious phenomenon is thus to be understood; in the sensitive fever a new sensorial power, viz. that of sensation, is superadded to that of irritation; which in other fevers alone carries on the increased circulation. Whence the power of irritation is not much more exhausted than in health; and those muscular motions, which are produced in consequence of it, as those which are exerted in keeping the body upright in walking, riding, and in the performance of many customary actions, are little impaired. For an account of the irritated sensitive fever, see ClassII. 1. 2. 1.; for the inirritated sensitive fever, ClassII. 1. 3. 1.IV. 2. 4. 11.
2.Febris a pure clauso.Fever from inclosed matter is generally of the irritated sensitive kind, and continues for many weeks, and even months, after the abscess is formed; but is distinguished from the fever from aerated matter in open ulcers, because there are seldom any night-sweats, or colliquative diarrhœa in this, as in the latter. The pulse is also harder, and requires occasional venesection, and cathartics, to abate the inflammatory fever; which is liable to increase again every three or four days, till at length, unless the matter has an exit, it destroys the patient. In this fever the matter, not having been exposed to the air, has not acquired oxygenation; in which a new acid, or some other noxious property, is produced; which acts like contagion on the constitution inducing fever-fits, called hectic fever, which terminate with sweats or diarrhœa; whereas the matter in the closed abscess is either not absorbed, or does not so affect the circulation as to produce diurnal or hectic fever-fits; but the stimulus of the abscess excites so much sensation as to induce perpetual pyrexia, or inflammatory fever, without such marked remissions. Nevertheless there sometimes is no fever produced, when the matter is lodged in a part of little sensibility, as in the liver; yet a white pus-like sediment in those cases exists I believe generally in the urine, with occasional wandering pains about the region of the liver or chest.
3.Vomica.An abscess in the lungs is sometimes produced after peripneumony, the cough and shortness of breath continue in less degree, with difficulty in lying on the well side, and with sensitive irritated fever, as explained in the preceding article.
The occasional increase of fever, with hard pulse and sizy blood, in these patients, is probably owing to the inflammation of the walls of the vomica; as it is attended with difficulty of breathing, and requires venesection. Mr. B——, a child about seven years old, lived about five weeks in this situation, with a pulse from 150 to 170 in a minute, without sweats, or diarrhœa, or sediment in his water, except mucus occasionally; and took sufficient nourishment during the whole time. The blood taken was always covered with a strong cupped size, and on his death three or four pints of matter were found in one side of the chest; which had probably, but lately, been effused from a vomica. This child was frequently induced to swing, both in a reciprocating and in a rotatory swing, without any apparent absorption of matter; in both these swings he expressed pleasure, and did not appear to be vertiginous.
M. M. Repeated emetics. Digitalis? Perseverance in rotatory swinging. See ClassII. 1. 6. 7.
Mr. I. had laboured some months under a vomica after a peripneumony, he was at length taken with a catarrh, which was in some degree endemic in March 1795, which occasioned him to sneeze much, during which a copious hæmorrhage from the lungs occurred, and he spit up at the same time half a pint of very fetid matter, and recovered. Hence errhines may be occasionally used with advantage.
4.Empyema.When the matter from an abscess in the lungs finds its way into the cavity of the chest, it is called an empyema. A servant man, after a violent peripneumony, was seized with symptoms of empyema, and it was determined, after some time, to perform the operation; this was explained to him, and the usual means were employed by his friends to encourage him, "by advising him not to be afraid." By which good advice he conceived so much fear, that he ran away early next morning, and returned in about a week quite well. Did the great fear promote the absorption of the matter, like the sickness occasioned by digitalis? Fear renders the external skin pale; by this continued decrease of the action of the absorbents of the skin might not those of the lungs be excited into greater activity? and thus produce increased pulmonary absorption by reverse sympathy, as it produces pale urine, and even stools, by direct sympathy?
M.M. Digitalis?
5.Febris Mesenterica.Fever from matter formed in the mesentery is probably more frequent than is suspected. It commences with pain in the bowels, with irritated sensitive fever; and continues many weeks, and even months, requiring occasional venesection, and mild cathartics; till at length the continuance of the pyrexia, or inflammatory fever, destroys the patient. This is an affection of the lymphatic glands, and properly belongs to scrophula; but as the matter is not exposed to the air, no hectic fever, properly so called, is induced.
6.Febris a pure aerato.Fever from aerated matter. A great collection of matter often continues a long time, and is sometimes totally absorbed, even from venereal buboes, without producing any disorder in the arterial system. At length, if it becomes putrid by its delay, and one part of the matter thus becomes aerated by the air given out by the other part; or if the ulcer has been opened, so that any part of it has been exposed to the air for but one day, a hectic fever is produced. Whence the utility arises of opening large abscesses by setons, as in that case little or no hectic fever is induced; because the matter is squeezed out by the side of the spongy threads of cotton, and little or no air is admitted; or by tapping the abscess with a trocar, as mentioned in ischias, ClassII. 1. 2. 18.
In this fever the pulse is about 120 in a minute, and its access is generally in an evening, and sometimes about noon also, with sweats or purging towards morning, or urine with pus-like sediment; and the patients bear this fever better than any other with so quick a pulse; and lastly, when all the matter from a concealed ulcer is absorbed, or when an open ulcer is healed, the hectic fever ceases. Here the absorbed matter is supposed to produce the fever, and the diarrhœa, sweats, or copious muddy urine, to be simply the consequence of increased secretion, and not to consist of the purulent matter, which was supposed to be absorbed from the ulcer. See Sudor calidus, ClassI. 1. 2. 3.
The action of the air on ulcers, as we have already shewn, increases the acrimony of the purulent matter, and even converts it into a weaker kind of contagious matter; that is, to a material inducing fever. This was ascribed to the union of the azotic part of the atmosphere with the effused pus in Sect. XXVIII. 2. but by contemplating more numerous facts and analogies, I am now induced to believe, that it is by the union of oxygen with it; first, because oxygen so greedily unites with other animal substances, as the blood, that it will pass through a moist bladder to combine with it, according to the experiment of Dr. Priestley. Secondly, because the poisons of venomous creatures are supposed to be acids of different kinds, and are probably formed by the contact of air after their secretion. And lastly, because the contagious matter from other ulcers, as in itch, or small-pox, are formed on external membranes, and are probably combinations of animal matter and oxygen, producing other new acids; but further experiments must determine this question.
It was thought a subject of consequence by the Æsculapian Society at Edinburgh, to find a criterion which should distinguish pus from mucus, for the purpose of more certainly discovering the presence of ulcers in pulmonary diseases, or in the urinary passages. For this purpose that society offered their first gold medal, which was conferred on the late Mr. Charles Darwin, in the year 1778, for his experiments on this subject. From which he deduces the following conclusions:
"1. Pus and mucus are both soluble in the vitriolic acid, though in very different proportions, pus being much the less soluble.2. The addition of water to either of these compounds decomposes it; the mucus thus separated, either swims on the mixture, or forms large flocci in it; whereas the pus falls to the bottom, and forms on agitation a uniform turbid mixture.3. Pus is diffusible through a diluted vitriolic acid, though mucus is not; the same occurs with water, or a solution of sea salt.4. Nitrous acid dissolves both pus and mucus; water added to the solution of pus produces a precipitate; and the fluid above becomes clear and green; while water and the solution of mucus form a dirty coloured fluid.5. Alkaline lixivium dissolves (though sometimes with difficulty) mucus, and generally pus.6. Water precipitates pus from such a solution, but does not mucus.7. Where alkaline lixivium does not dissolve pus, it still distinguishes it from mucus; as it then prevents its diffusion through water.8. Coagulable lymph is neither soluble in diluted nor concentrated vitriolic acid.9. Water produces no change on a solution of serum in alkaline lixivium, until after long standing, and then only a very slight sediment appears.10. Corrosive sublimate coagulates mucus, but does not pus.From the above experiments it appears, that strong vitriolic acid and water, diluted vitriolic acid, and caustic alkaline lixivium and water will serve to distinguish pus from mucus; that the vitriolic acid can separate it from coagulable lymph, and alkaline lixivium from serum.And hence, when a person has any expectorated material, the composition of which he wishes to ascertain, let him dissolve it in vitriolic acid, and in caustic alkaline lixivium; and then add pure water to both solutions: and if there is a fair precipitation in each, he may be assured that some pus is present. If in neither a precipitation occurs, it is a certain test, that the material is entirely mucus. If the material cannot be made to dissolve in alkaline lixivium by time and trituration, we have also reason to believe that it is pus." Experiments on Pus and Mucus. Cadell. London.
"1. Pus and mucus are both soluble in the vitriolic acid, though in very different proportions, pus being much the less soluble.
2. The addition of water to either of these compounds decomposes it; the mucus thus separated, either swims on the mixture, or forms large flocci in it; whereas the pus falls to the bottom, and forms on agitation a uniform turbid mixture.
3. Pus is diffusible through a diluted vitriolic acid, though mucus is not; the same occurs with water, or a solution of sea salt.
4. Nitrous acid dissolves both pus and mucus; water added to the solution of pus produces a precipitate; and the fluid above becomes clear and green; while water and the solution of mucus form a dirty coloured fluid.
5. Alkaline lixivium dissolves (though sometimes with difficulty) mucus, and generally pus.
6. Water precipitates pus from such a solution, but does not mucus.
7. Where alkaline lixivium does not dissolve pus, it still distinguishes it from mucus; as it then prevents its diffusion through water.
8. Coagulable lymph is neither soluble in diluted nor concentrated vitriolic acid.
9. Water produces no change on a solution of serum in alkaline lixivium, until after long standing, and then only a very slight sediment appears.
10. Corrosive sublimate coagulates mucus, but does not pus.
From the above experiments it appears, that strong vitriolic acid and water, diluted vitriolic acid, and caustic alkaline lixivium and water will serve to distinguish pus from mucus; that the vitriolic acid can separate it from coagulable lymph, and alkaline lixivium from serum.
And hence, when a person has any expectorated material, the composition of which he wishes to ascertain, let him dissolve it in vitriolic acid, and in caustic alkaline lixivium; and then add pure water to both solutions: and if there is a fair precipitation in each, he may be assured that some pus is present. If in neither a precipitation occurs, it is a certain test, that the material is entirely mucus. If the material cannot be made to dissolve in alkaline lixivium by time and trituration, we have also reason to believe that it is pus." Experiments on Pus and Mucus. Cadell. London.
7.Phthisis pulmonalis.In pulmonary consumption the fever is generally supposed to be the consequence of the stimulus of absorbed matter circulating in the blood-vessels, and not simply of its stimulus on their extremities in the surface of the ulcers; as mentioned in ClassII. 1. 5. and ClassII. 1. 3. 9. The ulcers are probably sometimes occasioned by the putrid acrimony of effused blood remaining in the air-cells of the lungs after an hæmoptoe. See ClassI. 2. 1. 9. The remote cause of consumption is ingeniously ascribed by Dr. Beddoes to the hyper-oxygenation of the blood, as mentioned Section XXVIII. 2.
As the patients liable to consumption are of the inirritable temperament, as appears by the large pupils of their eyes; there is reason to believe, that the hæmoptoe is immediately occasioned by the deficient absorption of the blood at the extremities of the bronchial vein; and that one difficulty of healing the ulcers is occasioned by the deficient absorption of the fluids effused into them. See Sect. XXX. 1. and 2.
The difficulty of healing pulmonary ulcers may be owing, as its remote cause, to the incessant motion of all the parts of the lungs; whence no scab, or indurated mucus, can be formed so as to adhere on them. Whence these naked ulcers are perpetually exposed to the action of the air on their surfaces, converting their mild purulent matter into a contagious ichor; which not only prevents them from healing, but by its action on their circumferences, like the matter of itch or tinea, contributes to spread them wider. See the preceding article, and Sect. XXXIII. 2. 7. where the pulmonary phthisis is supposed to be infectious.
This acidifying principle is found in all the metallic calces, as in lapis calaminaris, which is a calciform ore of zinc; and in cerussa, which is a calx of lead; two materials which are powerful in healing excoriations, and ulcers, in a short time by their external application. How then does it happen, that the oxygen in the atmosphere should prevent pulmonary ulcers from healing, and even induce them to spread wider; and yet in its combination with metals, it should facilitate their healing? The healing of ulcers consists in promoting the absorption of the fluids effused into them, as treated of in Section XXXIII. 3. 2. Oxygen in combination with metals, when applied in certain quantity, produces this effect by its stimulus; and the metallic oxydes not being decomposed by their contact with animal matter, no new acid, or contagious material, is produced. So that the combined oxygen, when applied to an ulcer, simply I suppose promotes absorption in it, like the application of other materials of the articles sorbentia or incitantia, if applied externally; as opium, bark, alum. But in the pulmonary ulcers, which cannot protect themselves from the air by forming a scab, the uncombined oxygen of the atmosphere unites with the purulent matter, converting it into a contagious ichor; which by infection, not by erosion, enlarges the ulcers, as in the itch or tinea; which might hence, according to Dr. Beddoes's ingenious theory of consumption, be induced to heal, if exposed to an atmosphere deprived of a part of its oxygen. This I hope future experiments will confirm, and that the pneumatic medicine will alleviate the evils of mankind in many other, as well as in this most fatal malady.
M. M. First, the respiration of air lowered by an additional quantity of azote, or mixed with some proportion of hydrogen, or of carbonic acid air, may be tried; as described in a late publication of Dr. Beddoes on the medicinal use of factitious airs. Johnson, London. Or lastly, by breathing a mixture of one tenth part of hydro-carbonate mixed with common air, according to the discovery of Mr. Watt, which has a double advantage in these cases, of diluting the oxygen of the atmospheric air, and inducing sickness, which increases pulmonary absorption, as mentioned below. An atmosphere diluted with fixed air (carbonic acid) might be readily procured by setting tubs of new wort, or fermenting beer, in the parlour and lodging-room of the patient. For it is not acids floating in the air, but the oxygen or acidifying principle, which injures or enlarges pulmonary ulcers by combining with the purulent matter.
Another easy method of adding carbonic acid gas to the air of a room, would be by means of an apparatus invented by Mr. Watt, and sold by Bolton and Watt at Birmingham, as described in Dr. Beddoes' Treatise on Pneumatic Medicine. Johnson, London. It consists of an iron pot, with an arm projecting, and a method of letting water drop by slow degrees on chalk, which is to be put into the iron pot, and exposed to a moderate degree of heat over a common fire. By occasionally adding more and more chalk, carbonic acid gas might be carried through a tin pipe from the arm of the iron pot to any part of the room near the patient, or from an adjoining room. In the same manner a diffusion of solution of flowers of zinc might be produced and breathed by the patient, and would be likely much to contribute to the healing of pulmonary ulcers; as observed by Mr. Watt. See the treatise above mentioned.
Breathing over the vapour of caustic volatile alkali might easily be managed for many hours in a day; which might neutralize the acid poison formed on pulmonary ulcers by the contact of oxygen, and thus prevent its deleterious quality, as other acids become less caustic, when they are formed into neutral salts with alkalis. The volatile salt should be put into a tin canister, with two pipes like horns from the top of it, one to suck the air from, and the other to admit it.