Chapter IV: Part 4

Morbillous symptoms are fever, impaired appetite, heaviness of the head and eyes, somnolency, catarrh, acrid defluxion from the fauces, nose, and eyes, with hoarseness, sneezing, and lachrymation; short dry cough, and some difficulty in respiration. Prior to the eruption, there is generally anxiety about the breast, palpitation of the heart, itching of the face, peevishness, and considerable fever. On the third or fourth day there is an eruption of small red spots first on the face, resembling the bites of ants or fleas, generally confluent and entangled, and broad on the trunk and extremities; but not elevated above the skin, nor rising into pustules, nor suppurating: the size and shape various and irregular. About the sixth day the eruption on the face begins to dry, and on the ninth, is totally obliterated with desquamation of the cuticle. With the eruption the fever frequently does not cease; and the cough and difficulty in respiration often continue beyond the eruptive limits and cuticular desquamation. The usual crisis is by scaling of the cuticle, turbid urine, or diarrhœa. Unfavourable symptoms are, too sudden or too tardy eruption; pale or yellow eruption; great debility; and above all, pulmonick inflammation. The last in the train of morbillous evils and consequences are, consumption, anasarca, ophthalmy. Sometimes, though rarely, measles have been seen in accompanyment with other eruptive fevers, as small pox, and gangrenous angina.

_Scarlet fever._ Febris scarlatina, ignis facer, scarlatina anginosa. Its mortality in the London bills is added to the general febrile heap. This contagious epidemick is most frequent in the infant and adolescent age; it attacks families and schools about one time; and the same person but once in life; and is said to be most frequent in winter. It is generally accompanied with an anginous or ulcerous sore throat, but not putrid. That genus or species of scarlet fever which usually accompanies angina gangrenosa, and is extremely dangerous, is hereafter described. The symptoms of simple scarlet are the usual febrile precursors; on the second, third, or fourth day, an eruption of broad irregular redness and spots; general or partial only over the face, trunk, and extremities, and not elevated above the surface: sometimes overspreading the face with a crimson colour. Concomitant symptoms are, difficulty of swallowing, and uneasiness in the throat, redness, tension, and sloughs: commonly also nausea, sickness at the stomach, vomiting, vertigo, drowsiness, headach, difficulty of breathing, anxiety. After three or four days more; that is, between the sixth and ninth, the cutaneous eruption and redness disappears, with desquamation of the cuticle, and harrassing pruriency. The usual crisis is by sweats, urine, fetid stools, and exscreation of sloughs. Sometimes, a few days after the cuticular desquamation, an anasarcous swelling suddenly appears; and during the convalescent state, from exposure to cold air, or neglect of cutaneous and other expurgation, anasarca, hydrothorax or ascites have ensued.

There are two or three other febrile eruptions to which authors have appropriated distinct names, but by which very few of the human race are destroyed. These are febris urticata, bullosa, and pemphigodes. In general, they consist of red spots and serous vesicles on different parts of the skin, exciting heat and itching; the urticata resembling blisters from the burning of nettles. Some of these are mobile, receding and re-appearing, and prone to relapse. After a few days, however, or at the utmost a few weeks, they vanish: and are not contagious nor epidemick.

_Plague._ Pestis. This febrile demon cannot now be called one of the mortal epidemicks of Europe, except in the south-east extremity, inhabited by the Turks. The two greatest pestilences on record, happened in the sixth and fourteenth centuries of our era; which, with more barbarous havock than that of Goths or Saracens, overwhelmed millions in three quarters of the globe in one indiscriminate massacre. In London, before the general conflagration in 1666, of one half nearly of the old city, the plague was very frequent: but since that event, or at the most two or three years after, it has been exterminated and banished from us. That fortunate disaster which consumed a magazine of putrefaction; together with widened streets, ventilation, cleanliness, and many other causes, have all contributed to the extinction of this exotick incendiary. For it is well known, that pestilential miasma has been preserved dormant many years in porous materials. From 1592 to 1665, the plague appears to have had annually more or less share in the mortality of the British metropolis; and adding together the different periods of its duration, amounts to twenty-five years. In 1665, which is the most furious pestilence in the London annals, the deaths amounted to 100,000; but in the eight preceding years, to only 113. Registers, in other parts of Europe, prove, that this disease has committed direful carnage since our emancipation. At Marseilles they can enumerate twenty general plagues, which have successively laid waste that populous city. Many other European cities and towns, during the last and present century, and especially those bordering on the Mediterranean, have, in a very short space of time, severely smarted by pestilence, and have been nearly depopulated.

At present, in all the Mediterranean ports they are, from fatal experience, scrupulously vigilant to guard, by a circumvallation of alarm posts, against the pestilential infection, and the clandestine entry of infected goods or merchandize. It rarely now gains admittance, by stealth into any of the European ports; (Constantinople excepted) or even if imported to our shores, the wise precautions and regulations, enacted by Quarantines, soon check its irruption and progress. This is a most interesting epoch and improvement in the police of modern states; for the original institution and rough draft of which, about 300 years ago, we are indebted to the Venetians. The political ordinances, however, enacted for the exclusion and suppression of pestilential contagion, were, until the present century, extremely erroneous and impolitick. Formerly, the plague in London, and in most other European cities, where it was permitted to sojourn, was rendered infinitely more terrifick and destructive by injudicious legislative regulations; especially by the barbarous sacrifice, and absurd policy of sick and sound immured together, with a forlorn motto on their doors, until all were dead or recovered. This was an effectual discouragement against an early alarm which, as in cases of fire, is of the utmost importance. It is evident, by the London bills, that a mere handful, at any time, died in the publick pest-house; consequently, every corner of the city was polluted with infection.

True plague is now chiefly chained down to Constantinople, and to Grand Cairo in Egypt, the two original, or at least one of the hotbeds and volcanos of pestilence; to several of the maritime towns of Asia and Africa situated on the Archipelago and Mediterranean; as Smyrna, Aleppo, Tripoli, Tunis, Algiers, &c. In many of these cities the pestilential miasma is hatched and accumulated into venomous malignity: it is in some nearly an annual, or triennial epidemick. At this day, plague almost solely wreaks its venom on the Mahometan nations, whose prejudices and ignorance, rivetted by religious and predestinarian absurdities, give licence and activity to its imperious domination. From such implicit and enthusiastick submission to the tenets of the Alcoran, joined to gross stupidity in science and philosophy, the Mahometans are encouraged, defenceless and rash, to brave this most malignant and terrible of the febrile host.

Fortunately for mankind, the pestilential contagion spreads to a very small distance through the air, without some contact or adhesion to infected goods and porous materials; or by personal communication and intercourse of the sound with the diseased. The atmosphere is not tainted to any considerable distance. A neighbour barricading himself within his house, at a few yards distance from infection, may escape unhurt. If pestilential contagion could be so suddenly and widely scattered over a kingdom as epidemical influenza, the earth, in a few months, would be converted into an enormous church-yard. It is not like some other exotick poisons of the exanthematous order, after enduring which once, mankind are rendered invulnerable: the plague, as well as putrid fever, may attack the same person repeatedly. What proportion die or recover, I cannot ascertain; and indeed the prophylactic or preventitive, is infinitely the most important indication. Its invariable characteristic features are buboes, carbuncles, and petechiæ. The general progress of the symptoms are, great abasement of strength and of spirits, apprehension of death, dejected countenance, and wildness of the eyes; nausea, vomiting of bile; headach, giddiness, delirium; weak irregular pulse; petechiæ, hæmorrhages; fetid breath and excretions; buboes or boils in the inguinal, axillary, or jugular lymphatick glands; and appearing early, or in the progress of the disease; besides gangrenous carbuncles in different parts. According to the virulence of the contagion, and other co-operating causes, the disease may be fatal in a few hours, a few days, or in one, two, or three weeks. The poison arrested in the lymphatic glands and suppurating, is a favourable presage. Domestick animals, as quadrupeds and fowls, are liable to the infection, and to be changed into carrion.

_Sweating Sickness_, ephemera sudatoria et elodes, cannot now be considered as an epidemick cause of mortality. Somewhat more than 300 years ago, this singular contagious and vagrant disease burst out, for the first time, in the army of Henry VII. in his return to England from an expedition against France; and in four hours sickness, numbers were exterminated: but by keeping warm in bed, under profuse sweats, the dangerous whirlpool generally was escaped. The same infection was imported into England at several subsequent intervals; but happily, its greatest devastation was always of short duration; and this morbid meteor has long since disappeared from our island, and from Europe. Its symptoms were continued profuse sweats, extreme debility, fainting, anxiety, restlessness, pain in the stomach, thirst, vertigo, quick irregular pulse. Sometimes it was fatal in one day; and, if the sick survived to the seventh, they generally recovered.

Of the predisposing and occasional _Causes_ of fevers, intermittent and remittent, nervous and putrid, inflammatory, small-pox, measles, scarlet, plague, sweating sickness. The principal causes of the preceding genera of fevers may conveniently be presented at one view, in abbreviation. We throw to one side all that specious romance and sapient pomposity, strutting in the tinsel robes of proximate causes, and merely attend to the predisponent and occasional. Because, after diving and climbing as assiduously as many of our fellow-labourers in search of those arcana, we experienced reiterated retrogradation; and, as in metaphysicks, error supplanted by error. Neither do we attempt to pry into those latent predispositions in the human organization, which renders them susceptible to many various febrile impressions.

The predisposing and occasional causes of intermittent and remittent fevers are, cloudy winter and autumn: northern morasses: noxious miasma or emanation from morasses, from countries and soils low, damp, woody, uncultivated, especially in warm climates, weather, and seasons: atmosphere moist and hot: foggy atmosphere: unusual irregularity of the seasons and atmosphere: unusual continuance of cold rainy weather: damp night-air, especially in warm unhealthy climates: excessive heats: burning zones and regions: sudden vicissitudes from heat to cold of the seasons and weather: unusually excessive and long continued heats: also damp weather, particularly when unusually warm for the season and climate: damp ground-floors and habitations: damp sheets and beds: sleeping in the open air, and on damp ground: sudden stoppage of perspiration: bile depraved, redundant; septick miasma introduced from without, or generated within the body: efforts of nature to disencumber its functions and organs of some clogs or impurities. Perhaps rather contributing as exciting causes are passions of mind, fatigue, hardships, long watching, hunger, thirst, intoxication, venery, interruption of the excretions, &c.

The predisposing and occasional causes of nervous and putrid fevers are, many or perhaps all of the preceding causes: noxious miasma or contagion, engendered from human effluvia in cities, jails, hospitals, dirty, small, crowded houses and apartments, especially in unventilated alleys and lanes; accumulation of corporeal filth from want of cloathing, change of raiment, slothfulness; contagion concentrated in porous materials, furniture, raiment, and houses: cadaverous exhalations, effluvia from putrid carcasses of animals, and from both animal and vegetable heaps in a state of fermentative putrefaction: damp rainy seasons: bad harvest, and putrid grain; putrid diet animal or farinaceous: improper medical treatment of remittent fevers; corrupted bile, or other secerned and excreted fluids, noxious in quantity or quality: profuse evacuation, immoderate venery, desponding passions of mind, intemperance in food or drink, stoppage of perspiration, &c. Of miliary fever the causes are, estuation, hot regimen, and rooms, during fever or parturition, excessive evacuations, weak constitutions, debility, depressing passions, moist air, wet summer.

The predisposing and occasional causes of inflammatory fevers and diary are, cold climate and winter: cold winds: change of seasons: heat of the atmosphere: insolation: excessive labour, exercise, and fatigue: violent passions of mind: long watching: cold drink when the body is heated: intoxication with spirituous liquors: crude chyle: heating stimulating diet: disordered stomach, plethora: excess of coagulable lymph and its tenacity: menstrual, lacteal, hæmorrhoidal, arthritick: warm baths; excruciating pain.

The predisposing and occasional causes of small pox, measles, scarlet fever, and sweating sickness, are unknown, both as to their source and nature: the two first are exotick leavens. Of plague: venomous effluvia in certain hot climates, from putrid animal exhalations and filth, such as the stagnant canals and reservoirs of putridity in the city of Grand Cairo: putrid emanations from swarms of dead locusts. Predisposing causes to pestilential infection are, long watching, hunger, poor diet, intemperance, excess of venery, fatigue, terror, fear, debility, low spirits, &c.

With respect to the great sources of fevers, noxious miasma from morasses, contagion from human effluvia, and animal bodies, and that from specifick unknown origin, I shall make a few observations. Of what elementary nature miasma and contagion consist; the analysis of their minute atoms; whether animalculæ, or to us invisible emanations, I pretend not to decide. Of small pox, measles, scarlet fever, and sweating sickness, we are totally ignorant of their origin and essence. We, however, know to a certainty, and it is of infinitely more importance to the publick safety, that neither marshy miasma, nor those from human effluvia, spread to any considerable distance through the air. Even by the plague the atmosphere is tainted to a very inconsiderable distance; and mankind find an asylum and sanctuary within a few yards. Nor do marshy miasma emitted from the earth, mount or diffuse themselves to any considerable distance in the air: the inhabitants at the top of a hill have continued healthy, whilst those situated in a swamp at the bottom, have been infested with intermittents, and remittents. To what distance the contagion of small pox, measles, and scarlet fever extend through the air, I am ignorant: like the plague, the two former have been transplanted to distant regions, in animal bodies, or in polluted porous materials. Another important discovery of modern times is, that by fire and smoke, the heat of a baker’s oven, the most virulent contagion may be annihilated, when concentrated in apparel, spungy materials, ships, houses, &c.

_Of Febrile Prognosticks._ The event of all the preceding fevers (intermittent excepted) is terminated with precipitancy in a few days, or, at the utmost, a few weeks in recovery, in death, or in some other disease. The predictions in fevers, and indeed in all diseases, should be deduced from the comparative mortality at different ages; the comparative mortality by different fevers; the symptoms peculiar to each genus, whether ominous or propitious; and the general symptoms applicable to an intire group or class. These enrich medicine with a rudder, compass and quadrant: in them consist the tactick and the sublime of medical divination. We have already treated of the three former, and have now only to add the general febrile predictions.

It is foreign to my plan, to squander time or words, in eulogy or censure of those elaborate treatises on the pulse and urine, and their presumed extensive application to the diagnostick and prognostick of diseases. Of strength and weakness, hardness and softness, fulness and inanition, slowness, celerity, velocity, saliency, intermission, irregularity, and a few other distinctions of the circulation and arterial pulsation, we are competent judges; and of the measurement of velocity to a still greater nicety with the stop-watch. But, with all due reverence to Galen and his copyists, down to De Bordeu, in discriminating the multitude and variety, if I may be permitted the expression, of complicated tones, combinations, divisions, subdivisions, chromaticks and chords in the arterial vibrations, we confess the bluntness and incapacity of our tangible organs. We have still fewer scruples to disclaim that affected sagacity and alchymistical intuition, of forming auguries from the urine; from its innumerable shades, intermixtures, pellicles, precipitation, and sediment. This is, even in our time, one of the decoys in vaticination to inveigle the ignorant and credulous; the stale manœuvres and chiromancy of vagabond empiricism and imposture.

A few words will finish our general remarks on the pulse. From physiology, we know that the whole mass of blood is circulated round the body from the heart, its lever and center, to the circumference, and back again, in the space of a few minutes. But in the velocity of the crimson torrent and arterial pulsation, prodigious variations ensue from age, sex, constitution, peculiar temperament, climate, season, food, drink, mental passions, exercise, rest, sleep, waking, health, different diseases, and different periods of the day. It is therefore, singly, a precarious sign; and did time permit, there would be no difficulty in demonstrating the urine to be infinitely more fallible. From infancy to old age, the velocity of the blood decreases, and is one half slower: in the adult and middle age, between sixty and eighty pulsations every minute is the usual natural pace: the febrile pulse is marked at 96, and is sometimes spurred to 130 or 140; and in infants sometimes outstrips the divisions of time or accurate mensuration.

All fevers with dangerous symptoms may be termed malignant; but in general, this term is appropriated to fevers, intermittent, remittent, nervous, putrid, exanthematous, and also to some of those complicated with topical inflammation. General prognosticks of danger are indicated by a concatenation of few or many of the following symptoms, which may, in some degree, be transposed to the intire febrile class; and to the phlogistick order not yet surveyed: as the brain, lungs, abdominal viscera, and organs indispensible to life, much deranged: debility in the executive and legislative functions; or vital, natural, and animal: signs of putrefactions.

We shall enumerate the principal of those in detail. The pulse weak, quick, fluttering, salient, irregular, intermittent, its systole duplicated, its velocity 130 or 140; tendency to faint or fainting in an erect posture; cold extremities: the respiration slow, laborious, quick, cold; all the subsidiary muscles of respiration labouring to distend the thorax; deep interrupted sighs, hiccup; particular noise in respiration, as if mucus plugged up the throat and lungs: the stomach very weak, with nausea, sickness, vomiting, desire of acids; deglutition difficult, struggling, and with noise; involuntary excretion of feces and urine; thirst; the tongue, teeth, and lips foul, and furred with a black gelatinous incrustation; the urine pale, red, black, fetid; intense burning heat in the abdomen; the belly tumid and puffed; fetid cadaverous smell and exhalations; clammy sweats, especially in the breast: the blood if drawn not coagulating: cutaneous petechiæ, like small bruises in different parts; subcutaneous effusions; hemorrhages: weakness, confusion, irregularity in the intellectual functions; the manners different from natural; in the speech or actions something unusual; loquacity; no sleep; coma or delirium furious, or low and muttering; in the countenance and eyes perturbation, agitation, amazement, despondency, despair, anxiety; attempts to rise out of bed; throwing off the bed-cloaths, incessant tossing about the bed; forgetfulness, loss of memory, so as not to know the nearest friend; refusing or exspuating food, drink, or medicines; moats floating before the eyes, and objects seen as through a cloud; total inattention to every object; twitching and spasms of the tendons at the wrist: catching and picking with the hands and fingers at the bed-cloaths, as if feeling for some object; starting of the muscles, convulsions; trembling of the hands and tongue when thrust out; supine posture; inability to support themselves erect or sitting; sliding down to the foot of the bed: livid nose; collapsed cheeks and temples; sunk and glazy eyes; dead, ghastly countenance, cold extremities.

It has been asserted by authors, that no certain febrile presages can be formed before the periodical crisis; but this is antiquated and erroneous. In tropical climates, the critical days are much more certain and evident than in northern regions: and as transmitted from the prognostical Alcoran of Hippocrates, are the 3d or 4th, 5, 7, 9, 11, 14, 17, 20; which amounts to rather more than one half critical, and the remainder non-critical. On such critical days the event is generally most decisive, whether salutary or fatal; in the non-critical it is a temporary respite. Besides, in tropical climates, the moon is observed to have considerable influence on febrile paroxisms, and crisis. As to the effect of febrile crisis on the human excretories, we have been sufficiently explicit. The favourable termination of fevers is chiefly discovered by cessation of delirium, abatement of the frequency of the pulse; mild sweats equally diffused; the urine depositing a sediment freely and copiously; coolness of the skin; return of natural sleep and appetite; and food recruiting the lost strength. The storm is then subsided, and the ship arrived at anchor.

* * * * *

The phlogistick group of febrile diseases are now to be reviewed. The majority of these in their immediate causes and mode of cure, intimately anastomose; and the principal differences in the symptoms are to be ascribed to the different organs and parts enraged by inflammation. These are not like the generality of the preceding fevers, in which most of the corporeal functions participate: here, in many cases, one single portion of the human organization is originally transfixed with pain and commotion; and doomed to bear the brunt of the hydraulick torrent and inundation. After mature consideration, we imagined it would occasion less confusion and burthen to the memory, to detach a few diseases from the phlogistick legion. Inflammation of the ears, eyes, intestines, kidneys, and bladder, are incorporated amongst the other diseases by which those various organs are liable to be invested. I am aware that this does not quadrate with the stiff etiquette of nosological parade: but, without digressing into a critical disquisition on this subject, I shall content myself with simply acknowledging that I am no convert to any of those modern pedagogues in morbid arrangement and nomenclature. With similar and intentional omission, I avoid the technical subtilities of parenchymatous and membranaceous inflammation.

_Inflammation of the Brain._ Phrenitis vera. As a primary disease, it is very rare in this kingdom. It is much more frequent in tropical and hot climates: and is the febrile calenture of those scorching regions. With us it is mostly symptomatick in different fevers: and may either affect the brain and medullary substance, or its investing membranes: and in the former case the delirium is said to be mild. Morbid dissections have proved, that when inflammation was believed to be present, none could be discovered; and in other cases, that the brain was inflamed, without expressing the usual symptoms. Of idiopathick phrenzy, the symptoms are, fever, excruciating and deep seated headach, restlessness, and want of sleep; intolerance of light and noise, with acute sensibility and irritability; red, prominent, ferocious eyes; audacious, and flushed countenance; contracted and languid pulse; throbbing of the temporal arteries; noise in the ears; change in the voice; impetuous delirium, and the patient, with difficulty, restrained in bed; dry parched tongue, but sometimes no complaint of thirst; costiveness; limpid urine. It is extremely dangerous and precipitate, terminating in a few days in recovery, death, or some other disease; and is rarely protracted beyond a week. The favourable crisis is various: by nasal hemorrhage, sweats, diarrhœa, turbid urine: but on any irregularity or intemperance, convalescents are prone to relapse. The predisposing and occasional _causes_ are, warm climate; insolation, especially with the head uncovered; sudden suppression of the puerperal lochia; intoxication; violent passions of mind; ambition, anger, grief, profound contemplation, unremitting study; long deprivation of sleep; external injuries; erysipelas, or scald head prematurely repelled; violent exercise; symptomatick.

_Angina:_ cynanche, quinsey; and distinguished into the inflammatory; and into the putrid, gangrenous, or malignant. The mortality by quinsey and sore throat, appears in the London bills inconsiderable; and without discrimination of the inflammatory and putrid. Inflammatory angina is a general and frequent affliction in both sexes, and especially in ours and some northern regions. Adults more than infants; and some individuals more than others, are obnoxious to it: its reign is in spring and autumn, on the change and vicissitudes of the seasons, or of heat and cold. In that very different species, the Gangrenous Angina, the ancient authors are nearly barren of information: some years this is epidemick and contagious in different parts of our island; and is much more inimical to childhood and adolescence than to adults; discharging its venom on schools, and the younger branches of families.

The principal differences in inflammatory angina are in the parts affected, and the degrees of inflammation; which may be in one or in both sides; and variously extended over the mucous membrane of the fauces, tonsils, velum, uvula, pharynx, and larynx. The usual symptoms are difficulty and pain in deglutition, and sometimes in respiration; internal intumescence and redness of the fauces, stiffness of the neck, and the lower jaw moved with pain; frequent and difficult in excreation of viscid mucus and saliva, and clamminess of the mouth and throat; impediment in the distinct articulation of words and speech; noise and darting pain in the ears; flushed face, prominent eyes; quick, strong, and hard pulse; anxiety, restlessness; sometimes considerable contiguous tumor externally; and in violent inflammation, necessity of an erect posture of the head, to prevent suffocation: the more the pharynx is affected, deglutition is proportionally interrupted; and some cannot swallow food or liquids during several days. The crisis is in a few days, at the utmost in a week or two, by resolution, or by suppuration; seldom or ever by gangrene. Resolution or discussion is accompanied with copious excreation and salivation; and frequently with critical perspiration, sweats, urine. Suppuration may be artificially discharged, or may spontaneously burst internally or externally. With judicious and opportune assistance, there is trifling danger. When fatal, it is by suffocation. The predisposing and occasional _causes_ are cold air inspired cold and moist air: perspiration suddenly checked, especially on the neck; cold water drank when the body is heated: epidemical influence of the air and seasons.

Inflammation principally attached to the muscles of the os hyoides, glottis, larynx, and trachea, is fortunately far less frequent than the former. In this, the current of air being intercepted, there is necessarily difficulty and pain in respiration, quick short breathing, sense of strangulation, great anxiety and restlessness; acute squeaking or ringing sound of the voice; quick and irregular pulse. Of that disease, which at least in symptoms has considerable analogy with the present, and called with us the Croup, we are hereafter to treat. We may here, however, with propriety, subjoin two other inflammations, the Angina Parotidea, and the Glossitis. The Angina Parotidea is often epidemick, but not dangerous. It commences as a glandular tumor externally, at the articulation of the lower jaw, becoming gradually more enlarged and unequally diffused, increasing to the fourth day, and from thence declining: and often is succeeded by swelling of the male testicles, or of the female breasts. The Glossitis is rarely a primary disease; but mostly complicated with angina, or venereal salivation. Its symptoms are obvious; pain and swelling of the tongue; speech and deglutition exercised with difficulty, headach, restlessness, flow of saliva. If violent in the extreme, there is danger of suffocation or starving.

The strong cardinal outlines in the features of Angina Gangrenosa are, symptoms of nervous and putrid fever, with ulcerations in the tonsils. Upon these we shall enlarge in their rotine and detail: soreness or uneasiness in the fauces and throat; stiffness of the neck; headach, nausea, and vomiting; the fauces and tonsils inflamed, but seldom in any considerable degree, of a shining crimson colour, with ash-coloured spots on the tonsils, and sloughs, forming soon into corroding ulcers; some pain is felt in deglutition; there is sudden prostration of strength; depression of spirits; anxiety and oppression at the breast; small, quick, and fluttering pulse; dizziness in the head; slight delirium, especially at the nocturnal exacerbation; heavy, red, and watery eyes; the tongue foul at the root; in some the voice hoarse; and in most the nostrils excoriated by a sharp defluxion; the breath unusually fetid, and generally the fecal discharge: the external tumor of the fauces, when visible, which, so far as my experience reaches, was rarely the case, is edematous, indenting by pressure. In most cases there is a cutaneous efflorescence overspreading the face, neck, and other parts of the body, in small points, scarcely eminent, or in confused and confluent blotches: the period of this eruption and of its duration varies; and with its recedence there is desquamation of the cuticle.

This is infinitely more dangerous than the inflammatory angina, terminating salutary or fatal from the third to the seventh day, according to the degrees of virulence and medical aid. Alarming symptoms are, great debility; cutaneous petechiæ; the internal functions of the brain much deranged; weak, quick, fluttering, and irregular pulse; livid colour of the ulcers; refusal of drink and medicine; together with the other inauspicious symptoms enumerated under febrile prognosticks in general. I have seen not only petechiæ, but also putrescent hemorrhages from the nose and gums in this disease. At the crisis there are often fetid stools; but whether critical, or from the acrid matter swallowed, may be disputed. General sweats and excreation of the ulcerous sloughs are favourable omens. By the speedy and judicious assistance of remedies and regimen, very few, compared to the sick and infected, sink. It is epidemick and contagious: but of the source or nature of the contagion, we are unacquainted.

_Inflammation of the Lungs and Organs of Respiration_, is a frequent inflammation in northern climates; and most so in spring, autumn, and winter; when the body, hydraulick canals, and blood are in a state of inflammatory diathesis: it generally encounters the robust vigorous constitution, those of strong muscular fibre, and dense rich blood; the athletick rustick, manufacturer, and artizan; those in the prime, and in all the intervals between twenty and the decline of life: it is very rare in infancy, as in idiopathick disease, and seldom under puberty, or in old age. It is most universal amongst the male sex; and in all probability, both more universal and destructive amongst the necessitous laborious mass of the community. We also read in authors, of spring pleurisies as no unusual affliction in some climates considerably nearer to the equator than ours. I apprehend, that in the London registers the mortality by pulmonick inflammation is under-rated, and perhaps delegated to imposthume and consumption.

Nosologists have enumerated several extraneous symptoms as complicated species of pleurisy and peripneumony; such as bilious, erysipelatous, catarrhal, rheumatick, intercostal, arthritick, verminous, flatulent, scorbutick, putrid, and malignant: most of which are merely symptomatick: for neither rheumatick pains in the intercostal muscles, nor flatulence pent up in the intestines, can impose on medical discernment as genuine pleurisy. The primary seat of pulmonick inflammation, whether in the parenchyma or internal viscus, or in its investing membranes, is not clearly established in medical diagnosticks; and therefore we comprehend pleurisy and peripneumony under one genus: in most cases they are complicated; and it is now doubted whether any pure peripneumony occurs without the pleura also participating in the affliction. The inflammation confined to the pleura alone, was described as unaccompanied with expectoration; hence the distinction of dry and humid species; and in genuine pleurisy the pain was represented as more acute than in peripneumony.

The symptoms of pulmonick inflammation are fever, darting pungent pain fixed like a dagger in some part of the chest, the side, breast, or back; and sometimes shooting to the scapula and clavicle: sometimes the pain is more dull and obtuse; and its situation oftenest in the side, about the middle of the ribs, between the sternum and spine; and commonly confined to one lobe. At the invasion there is shivering, restlessness, anxiety, succeeded by heat: hot accelerated laborious respiration; load and oppression at the breast; urgent, short, and painful cough; and very early in the disease more or less expectoration, streaked with blood; the pain is exasperated by inspiration and coughing, and mostly fixed, but sometimes veering or shifting: the pulse quick, full, hard, and tense, like a stretched chord; the blood drawn forms a buffy tenacious crust on the coagulum; the urine is of a florid colour: from the violence of pain, patients are often unable to lay on either side, but compelled to recline half-erect on their backs: when the inflammation is violent, or both pulmonick lobes assailed, there is inexpressible anxiety and struggle in respiration, florid countenance, prominent eyes; with other symptoms of obstructed circulation, and return of blood from the head, and menacing suffocation. In the advanced or dangerous stage of the disease, the pulse is weak, soft, and irregular. Sometimes there is nausea of the stomach; and sometimes delirium.

The termination of pulmonick inflammation is by resolution, by suppuration, by gangrene, by fatal effusion of blood, or exudation of coagulable lymph into the cellular texture. Favourable symptoms are, as in anginous excreation, facility in expectoration, without much exertion or coughing, copious, of due consistence, a little yellow, white, thick, slightly streaked with blood; the sooner this is concocted and excreted, the sooner is the crisis; less urgent and painful cough; freer breathing; abatement in the heat of the body and velocity of the pulse; general perspiration; deposition of sediment in the urine; nasal hemorrhage; dispersion of the pain, hitherto fixed in the thorax, about the shoulders, back, or arms; erysipelas in some external part; pustular eruption about the breast, neck, and scapulæ; abscesses in different parts. A crisis, when favourable, always ensues within seven, or at the utmost fourteen days; and after such crisis, expectoration may continue copious several days.

Inauspicious symptoms are, the respiration struggling and laborious in the extreme; dry pertinacious cough; no expectoration, or with difficulty; suppressed expectoration; obtuse pain, with difficult respiration; frequent violent cough exasperating the pain; the pain changing from one side into the other; the pulmonick lobes in both sides inflamed; the breathing intolerable and suffocating, except in an erect posture, and even then with laborious anxiety; the face turgid and florid, or pale, with features of consternation; violent headach; delirium; remission succeeded by relapse; excessive sweats; dry skin; weak, soft, and irregular pulse; sudden cessation of pain; grumous livid expectoration; rattling noise in the thorax, as if plugged up by phlegm; dejected countenance, squalid sunk eyes; great prostration of strength; cold clammy partial sweats; limpid urine; florid blood coughed up, or white and glutinous matter resembling the branches of blood-vessels. Effusion of blood, and exudation of coagulable lymph into the pulmonary cellular texture, bronchial vesicles and air-pipes, is more frequently than gangrene, the cause of suffocation and death. The occurrence of either is seldom later than fourteen days. There is also great danger of pulmonick inflammation, persevering beyond seven or, at the utmost, fourteen days, and without any considerable remission or signs of resolution, terminating in suppuration; of which the diagnosticks are hereafter marked. Authors have likewise described a malignant peripneumony, which seems to be a complication of the preceding deleterious symptoms, and of putrid fever.

There is, however, a species of pulmonick affliction, the specifick diagnosticks of which it would be unpardonable to omit; because it has often and fatally been either confounded with, and treated as genuine pulmonick inflammation, or slighted as a catarrh. This is named Peripneumonia Notha; whose symptoms, at the onset, are ambiguous. It is most frequent in persons old, phlegmatick, fat, weak, emaciated, subject to catarrh, addicted to fermented and spirituous liquors; and in foggy weather and rainy winters. It appears in the same seasons with genuine pulmonick inflammation, and with catarrh; that is, in spring and autumn; and frequently under the veil of a violent catarrh. The fever and heat are inconsiderable; the pulse not hard nor tense; but there is straitness and difficulty of breathing, and load at the breast, with anxiety and gasping for breath; urgent violent cough, with some expectoration, and sometimes exciting vomiting; giddiness of the head; rending headach; sometimes drowsiness. It is sometimes suddenly and unexpectedly aggravated, and suffocates the patient.

The predisposing and occasional _causes_ of pulmonick inflammation are, epidemick state of the air; sudden vicissitudes of the seasons and weather from heat to cold; sudden suppression of perspiration, or of pulmonary exhalation; inspiration of cold air; sudden exposure to keen cold air, especially after breathing in a warm room, or drinking warm liquors; cold liquors drank when the body is heated; intemperance and sottishness, particularly in spirituous liquors; dry cold winds; strong muscular exercise, or manual labour; repulsion of cutaneous eruption, febrile or chronic; exsiccation of old ulcers; suppression of habitual evacuation and eruption; translation to and deposition of morbid matter on the lungs; consequence and dregs of small pox and measles; symptomatick from some other diseases.

Inflammations of the heart, mediastinum, and diaphragm, as solitary, are very rare diseases. The symptoms of Carditis are severe fever; pain and anxiety in the region of the heart; difficulty of breathing; cough; irregular pulse; palpitation, syncope. Inflammation of the diaphragm, paraphrenitis: the symptoms are, acute fever, intense pain in the breast darting to the back, and increased by inspiration, coughing and sneezing, and by natural exertion at stool and urine; restlessness, anxiety, dry cough, quick convulsive breathing; sneezing, hiccup, nausea, vomiting; compulsive painful grin on the countenance, delirium. When it occurs, it is generally complicated with inflammation of the adjacent organs, in either the thorax or the abdomen. As the heart is the main spring of the blood’s circulation, and the diaphragm the principal agent in respiration, it is evident that inflammation in either must be extremely dangerous.

_Inflammation of the Liver_, hepatitis, acute and chronic. Both species are much more frequent in tropical climates and warm regions, than in northern and cold; and more so in the former during the hottest seasons of the year. The sensibility of the liver being dull, its inflammation is less painful than that of any other viscus. The symptoms are, fever, pain in the right side under the false ribs, and felt at the corresponding clavicle, scapula, and hand; sensation of heat and heaviness in the hepatick region; difficulty of breathing, more especially when the inflammation invests the superior convex part of the liver; there is often dry cough; nausea, bilious vomiting, and diarrhœa; the urine of a fiery or saffron-colour; and generally, but not always, the eyes, countenance, and skin more or less of a jaundice tinge; the pulse not remarkably disturbed; but thirst. Sometimes hepatick inflammation is entangled with that of some contiguous organs of the lungs or abdomen, and with their respective features. The acute hepatitis, but not the chronic, is usually terminated in a few days, at the utmost fourteen or twenty-one, by discussion, suppuration, or gangrene. Critical resolution may be variously accompanied with bilious diarrhœa and urine, nasal or hemorrhoidal hemorrhage, copious bilious sweats. Suppuration is not an unfrequent termination: after which many survive, but with difficult and slow recovery. The purulency may be expurgated by absorption, by the biliary ducts, by erosion of the abdominal muscles, or by an artificial opening when the abscess is perceptible externally; and sometimes it erodes the diaphragm and lungs.

The predisposing and occasional _causes_ are, burning climates; acrid viscid bile; the blood tenacious and glutinous in consistence; calculi, steatome, worms in the biliary ducts; bilious vomiting; sudden refrigeration of the body when heated, and obstructed perspiration; thirst, and not sufficient dilution of the blood; intoxication and abuse of spirituous liquors; poisons; external injuries; violent exercise; passions of mind; inveterate hypochondriasm; translation of purulent matter to the liver; symptomatick.

Inflammation of the Spleen is a rare occurrence: schirrus of that organ is far more frequent. The Peritonitis is also an uncommon inflammatory vagrant: it will be revived hereafter under Puerperal Fever.

_Inflammation of the stomach_, gastritis. Notwithstanding the incessant irritation and distinction of this sensible organ, by innumerable varieties of food and drink, yet its inflammation is a rare event. The symptoms, acute fever; fixed burning pain and heat in the region of the stomach, aggravated by pressure; frequent nausea and vomiting after taking any nourishment; anxiety, restlessness; weak, hard, intermittent pulse; frequently delirium; universal debility. It may prove fatal in the space of a few days, or even of a few hours: there are different gradations of severity and danger. The termination is by resolution, suppuration, gangrene. The predisposing and occasional _causes_ are, all the causes of topical inflammations in general; poisons swallowed; cold water, ices, and fruits swallowed when the body is much heated; repletion from food and gormandizing; crude and difficultly digested nutriment; violent agitation of body or mind; external injuries: from repelled gout very rarely.

The three succeeding genera of the phlogistick tribe, so far as respects mere inflammation only, affect the external parts and circumference of the body, and do not suppurate. In other respects there is a distinct tripartite separation, both as to general outlines and minuter shades.

_Erysipelas_, ignis sanct. antonii: gutta rosacea, zoster, zona, herpes. Some trifling pillage by this disease is noticed in the London bills. To adults it is most hostile. The symptoms are, more or less fever; superficial inflammation of some portion of the skin and cuticular membrane, with pain, tumefaction, burning heat, redness, and pruriency, like that from nettles; and variously, in different persons, assailing the face, the neck, the trunk, or one of the extremities: the eruption seldom appears until after the commencement of the febrile commotion; and often from a small point spreads gradually: it never rises to any conical eminence, nor suppurates, but often excites vesications; and if on the face and violent, blocks up the eyelids: the pulse is frequently full and hard; and with the eruptive expulsion the fever and heat do not cease. It is sometimes critical and salutary: the favourable crisis is usually in a few days, or within nine, by perspiration, urine, and desquamation of the inflamed cuticle; and sometimes without any perceptible revulsion to the excretories. Some have this cutaneous inflammation annually, or oftener, or at wider intervals; and those once affected, are more obnoxious to its returns. Presages of danger are, violent inflammation and intumescence on the face, or sometimes even on the legs, particularly in old age, or unsound constitutions; premature retrocession of the eruption; pale colour; frequent return, and repetition of the inflammation; delirium; coma; gangrene. On the legs it sometimes leaves behind a chronic enlargement. The zoster and zona is a species of erysipelatous inflammation, a hand’s breadth or more, affecting the breast, sides, or abdomen, and various in length.

The predisposing and occasional _causes_ of Erysipelas are, epidemick influence of the air; obstructed perspiration; sudden refrigeration of the body when heated; plethora; suppressed evacuations, natural or artificial; luxurious living and indolence; intemperance; spirituous liquors in excess; poisons; unsound constitutions; contusions, wounds, burns, punctured nerves, blisters, acrids; dregs of fevers; scorbutick; lunar influence; passions of mind.

_Rheumatism, acute and chronic._ From the Chart of diseases we may rank rheumatism as an inferior piratical foe amongst the morbid host; or rather as a scourge and instrument of torture than of execution. In the acute or chronic form, multitudes are molested by it, especially in this island, and in northern regions: and more so in winter, in spring, and autumn, and the interchanges of the seasons: it seldom molests very young or aged persons: adults are most annoyed by it; the male more than the female sex; the poor and indigent more than the affluent; and those most who are exposed to the inclemency and vicissitudes of the seasons and weather: hence, during war, soldiers and sailors are much more afflicted with it than in peace.

In the acute rheumatism, fever may commence before or after the pain, which variously and alternately seems to dilacerate different parts, especially about the joints of the ancles, knees, hips, shoulders, elbows, and wrists, sometimes the trunk; but rarely the small joints of the toes or fingers: and commonly succeeded by swelling and redness of the distracted joints, and with restlessness: at night the pains are exasperated, and often suddenly abating in one joint, seize upon another; thus harassing the body with a war of posts. In its diagnostic train also are, hard quick pulse, sizy blood, inflammatory urine; sweats sometimes copious, but not critical. Its continuance may be one, two, or three weeks; by which time the fever, if not mismanaged, abates with the pains: it very rarely terminates in suppuration, and in this instance resembles erysipelas and gout. The crisis of the acute is generally by sweats, cuticular efflorescence, nasal hemorrhage. It may terminate inauspiciously in chronic pains, or in consumption: indeed, emaciation is always a consequence.

Chronic rheumatism may occupy all the stations of the acute: in the hips it is called ischias, morbus coxendicis, and sciatica: in the loins, lumbago. In this there is no fever, redness, nor swelling, only pain and often inability to move the affected joints; and this aggravated by change of weather and cold. In the lumbago there is direful pain about the loins, with difficulty in erecting the trunk; but not, as in the nephritis, accompanied with nausea or vomiting, nor pain of the ureters, testicles, or thighs. In the ischias there is severe fixed pain about the hips, os sacrum, and pubis, and often extending down the thigh and leg along the fascia aponeurotica; with difficulty or incapacity of moving the thigh; and sometimes atrophy of that extremity, or sciatic tabes. Chronic rheumatism may harass months, years, with various degrees of severity and exacerbation, and interludes of ease; and is often extremely obstinate and difficult to be dislodged. In many instances also, we observe a contrariety and dilemma whether to affix the name of chronic rheumatism or gout to such pains. In general, rheumatic aches are not so periodical in their returns; and in several other features the two diseases divaricate.

The predisposing and occasional _causes_ of acute and chronic rheumatism, idiopathic and symptomatick, are, sudden suppression of perspiration; sudden heats and colds; cold damp night air, beds, houses, habitations, want of sufficient warm cloathing and fuel in rigorous seasons, or during the interchanges of the seasons; wet cloaths; exposure to heats and colds; sudden vicissitudes of heat and cold; change of winds and weather; one part of the body exposed to cold whilst the other part is heated; sleeping on damp ground; plethora; impure blood; repelled eruption; suppressed evacuations; habitual intoxication; intermittent; dregs of fever; arthritic; hereditary; scorbutick; hysterical; venereal; noxious exhalation from lead or mercury; excess of venery; tabes dorsalis; aneurism of the descending aorta near the loins; lifting great weights; internal abscess and scirrhus; abscess, and caries at the upper articulation of the thigh-bone; sprains; luxation and fracture of its neck; diseases of the coverings of the nerves, or of their medullary substance, or of the muscular fibre.

_Gout_, arthritis, podagra; acute, chronic, regular, and irregular. Here we have no foundation to accuse the elements, or the invisible demons of disease: this malady either immediately, or by hereditary descent, is too often the natural castigation and penance of voluptuousness and sensuality. In the preceding century it was confounded with sciatica in the London bills. During the present century, there is a considerable increase in arthritic mortality; but, compared to some other of the morbid host, it is a mere buccanier. Arthritic piracy must solely be imputed to the assaults of chronic gout, either gradually breaking down the fabrick, or storming some of the internal organs essential to life. It attacks principally the male sex; sometimes, but rarely, females; and of the latter those of robust full habits, the viragines, luxurious, indolent, corpulent, and generally after the final menstrual cessation: the majority, from the peculiarity in the female constitution, and from superiority in temperance, are exempt. It seldom attacks before middle age; generally in the decline of life: the few exceptions of its earlier occurrence are rare; and in them it is usually by co-operation of hereditary, and of remote exciting causes: in adolescence, and before puberty, it would be numbered amongst the medical miracles. It harasses most those of robust, full, corpulent, large frame and temperament, the voracious, gormandizing, affluent, and pampered; more of the patrician than the plebeian orders; more of the literary and sedentary professions; and, according to Sydenham, those of an acute genius and intellectual eminence. The active and industrious orders of every community; those who are exercised in daily corporeal labour, or who, from necessity, design, custom, or religion, do not indulge to excess in animal food, or in wine and fermented liquors, are seldom arthritick martyrs. Compared to the number afflicted, very few die of gout; it has even been by some considered as an omen of longevity: many, subject to it, have reached the Mosaick goal. It has been alledged, to render men more secure from other diseases; and in some few instances to expurgate and renovate a disordered constitution. These observations, however, must be restricted to regular gout only, and recurring at distant intervals.

That periodical local pain and inflammation called the regular arthritic paroxism sometimes invades suddenly, without any warning; but in general there are presages of its approach, one or two days, or even weeks; by ceasing of usual moisture on the feet; coldness, numbness in the feet and legs, enlargement of their veins, muscular cramps; general torpor and languor; restlessness; headach; depression of spirits; impaired appetite; flatulence, indigestion, cardialgy; costiveness. But frequently one or two days preceding the paroxism, the appetite is keener than usual. The regular and recent paroxism commonly invades by nocturnal surprize in bed, with pain in one foot, usually the ball of the great toe, accompanied with shivering, heat, and shortly after, conspicuous glossy redness, tension, and spreading tumor. The pain becomes often so intense as to be compared to premeditated dislocation, or to a dog tearing the flesh and ligaments: and such is the exquisite tenderness in the inflamed part and foot, as not to be able to tolerate the slightest touch or even weight of the bed-cloaths. In this way there are more or less diurnal remissions and exacerbations of pain; which, after one, two, three, or four weeks, recedes gradually and insensibly, together with the redness and swelling; leaving the patient who had been chained to a bed or couch, in perfect health; and soon after, the foot in the exercise of its former suppleness and strength. Throughout the paroxism the corporeal agony renders the mind more irritable and irascible: the urine is acrid, hot, turbid, and fabulous; in many, the perspiration is fetid; and with both general and local sweats, and desquamation of the inflamed cuticle, the paroxism finally evaporates. In vigorous constitutions the paroxisms are sooner terminated: indications of which are, sudden tumefaction, throbbing pain, and frightful sleep. In recent gout the pain is more severe than in chronic; the paroxisms shorter, with longer intervals; and _vice versa_. Pustular eruptions on the foot sometimes carry off the arthritic fuel.

At the beginning, the paroxisms are shorter, and the periods more regular and distant; at intervals of three or four years, or longer: by degrees the intervals are progressively reduced to two, to one; to two paroxisms annually about the equinoxes and solstices, and during the autumn, winter, and spring; at the same time the paroxisms are protracted to two or three months. At length, in the chronic inveterate stages of the disease the patient enjoys a very short respite; some few of the enervated, perhaps only two or three months during the summer: the pains in the extremities are then indeed less violent; but the stomach is more disordered. In recent gout, one foot only is assaulted; by degrees both feet, one after the other: and in the rooted state of the disease it not only torments both feet in succession, but capriciously deserts and re-attacks various parts; the ancle, knee, elbow, wrist; darting often with electrical velocity and shocks through the nerves and muscular fibres: thus, in a circle of torture and litigious warfare, teazing the arthritick victim.