Part 9

If the Disease has been of several Days Duration, when I have first been called; if the Fever is still very high; if there be a Difficulty of Breathing; if the Patient does not expectorate at all, or brings up too much Blood; without being too solicitous about the Day of the Disease, the Patient should be bled, though it were on the tenth.

Sec. 51. In this, and in all other inflammatory Diseases, the Blood is in a very thick viscid State: and almost immediately on its being drawn, a white tough Skin, somewhat like Leather, is formed on its Top, which most People have seen, and which is called the pleuritic Crust. It is thought a promising Appearance, when at each Bleeding it seems less hard, and less thick, than it was at the preceding ones: and this is very generally true, if the Sick feels himself, at the same Time, sensibly better: but whoever shall attend solely to the Appearance of the Blood, will find himself often deceived. It will happen, even in the most violent Inflammation of the Breast, that this Crust is not formed, which is supposed to be a very unpromising Sign. There are also, in this Respect, many odd Appearances, which arise from the smallest Circumstances; so that we must not regulate the Repetitions of our bleeding, solely by this Crust: and in general we must not be over credulous in supposing, that the Appearances in the Blood, received into the Bason, can enable us to determine, with Certainty, of its real State in the Body.

We should however, with the greater Circumspection (of how much the longer standing the Disease has been, and by how much the more difficult the viscous Humours are to be melted down and dislodged) attend to the Coction of the Matter of Expectoration; which Nature does not often easily effect, and which she effects the more imperfectly and slowly, the weaker he is. Her last Efforts have often been attended with such high Paroxysms, as have imposed even upon very competent Physicians, and have made them open a Vein a few Hours before the Patients' Death, from their Pulses being strong, hard and frequent. Excessive Weakness is the Sign, by which we may discover such unavailing Efforts to be the last. E. L.

Sec. 52. When the sick Person is in the Condition described (Sec. 47) the Bleeding is not only unattended with Ease; but sometimes it is also pernicious, by the sudden Weakness to which it reduces him. Generally in such a Case all Medicines and Means are insignificant: and it is a very bad Sign in this Disease, when this Discharge is not attended with Ease and Benefit to the Sick; or when there are some Circumstances, which oblige us to be sparing of it.

Sec. 53. The Patient's Legs should every Day, for one half Hour, be put into a Bath of warm Water, wrapping him up closely; that the Cold may not check that Perspiration, which the Bath promotes.

Sec. 54. Every two Hours he should take two Spoonfuls of the Mixture No. 8, which promotes all the Discharges, and chiefly that of Expectoration.

Sec. 55. When the Oppression and Straitness are considerable, and the Cough dry, the Patient may receive the Vapour of boiling Water, to which a little Vinegar has been added. There are two ways of effecting this; either by placing below his Face, after setting him up, a Vessel filled with such boiling hot Water, and covering the Patient's Head and the Vessel with a Linen Cloth, that may inclose the Steam; or else by holding before his Mouth a Spunge dipped in the same boiling Liquor. This last Method is the least effectual, but it fatigues the Patient considerably less. When this bad Symptom is extremely pressing, Vinegar alone should be used without Water; and the Vapour of it has often saved Patients, who seemed to have one Foot in the Grave: but it should be continued for several Hours.

Sec. 56. The outward Remedies directed in No. 9. are also applied with Success to the Breast, and to the Throat.

Sec. 57. When the Fever is extremely high, the Sick should take every Hour, a Spoonful of the Mixture No. 10. in a Cup of the Ptisan but without diminishing on this Account the usual Quantity of his other Drinks, which may be taken immediately after it.

The Use of Acids, in Inflammations of the Breast, requires no little Consideration. Whenever the sick Person has an Aversion to them; when the Tongue is moist, the Stomach is heavy and disordered, and the Habit and Temperament of the Patient is mild and soft; when the Cough is very sharp without great Thirst, we ought to abstain from them. But when the Inflammation is joined to a dry Tongue, to great Thirst, Heat and Fever, they are of great Service. Slices of China Oranges sprinkled with Sugar may be given first; a light Limonade may be allowed afterwards; and at last small Doses of the Mixture, No. 10. if it becomes necessary. E. L.--I have chosen to retain this Note of the Editor of Lyons, from having frequently seen the Inefficacy, and sometimes, I have even thought, the ill Effects of Acids in Peripneumonies and Pleurisies, in a Country far South of Swisserland; and where these Diseases are very frequent, acute and fatal. On the other hand I shall add the Substance of what Dr. Tissot says on this Head in a Note to his Table of Remedies, wherein he affirms, that he has given in this Disease very large Doses of them, rising gradually from small ones, and always with great Success; intreating other Physicians to order this Acid (the Spirit of Sulphur) in the same large Doses which he directs in this Chapter, and assuring himself of their thanks, for its good Consequences--Now the only ill Effect I can surmize here, from shewing this Diversity of Opinion in these two learned Physicians, and my own Doubts, is, that the Subjects of this Disease in Country Places may prove somewhat confused and irresolute by it, in their Conduct in such Cases. But as all of us certainly concur in the great Intention of doing all possible Good, by the extensive Publication of this Treatise, I shall take leave to observe that in this Disease, and in Pleurisies, more solid Benefit has been received in Carolina, Virginia, &c. from the Use of the Seneka Rattle-snake Root, than from any other Medicine whatever. Bleeding indeed is necessarily premised to it; but it has often saved the Necessity of many repeated Bleedings. This Medicine, which is termed in Latin, the Polygala Virginiana, is certainly rather of a saponaceous attenuating Quality, and betrays not any Marks of Acidity, being rather moderately acrid. There will be Occasion to mention it more particularly in the subsequent Chapter, as such a Liberty can need no Apology to any philosophical Physician. K.

Sec. 58. As long as the Patient shall grow worse, or only continue equally bad, the same Medicines are to be repeated. But if on the third Day (tho' it rarely happens so soon) or fourth, or fifth, the Disease takes a more favourable Turn; if the Exasperation returns with less Violence; the Cough be less severe; the Matter coughed up less bloody: if Respiration becomes easier; the Head be less affected; the Tongue not quite so dry; if the high Colour of the Urine abates, and its Quantity be increased, it may be sufficient then to keep the Patient carefully to his Regimen, and to give him a Glyster every Evening. The Exasperation that occurs the fourth Day is often the highest.

Sec. 59. This Distemper is most commonly terminated and carried off by Expectoration, and often by Urine, which on the seventh, the ninth, or the eleventh Day, and sometimes on the Days between them, begins to let fall a plentiful Sediment, or Settling, of a pale red Colour, and sometimes real Pus or ripe Matter. These Discharges are succeeded by Sweats, which are as serviceable then, as they were injurious at the Beginning of the Disease.

Sec. 60. Some Hours before these Evacuations appear, there come on, and not seldom, some very alarming Symptoms, such as great Anguish; Palpitations, some Irregularity in the Pulse; an increased Oppression; convulsive Motions (this being what is called the Crisis, the Height, or Turn of the Distemper) but they are no ways dangerous, provided they do not occasion any improper Treatment. These Symptoms depend on the morbid and purulent Matter, which, being dislodged, circulates with the Humours, and irritates different Parts, until the Discharge of it has fairly begun; after which all such Symptoms disappear, and Sleep generally ensues. However I cannot too strongly insist on the Necessity of great Prudence in such Circumstances. Sometimes it is the Weakness of the Patient, and at other times Convulsions, or some other Symptoms, that terrify the By-standers. If, which is most generally the Case, the absurd Practice of directing particular Remedies for such Accidents takes place, such as spirituous Cordials, Venice Treacle, Confections, Castor and Rue; the Consequence is, that Nature being disturbed in her Operations, the Crisis or Turn is not effected; the Matter which should be discharged by Stool, by Urine, or by Sweat, is not discharged out of the Body; but is thrown upon some internal or external part of it. Should it be on some inward part, the Patient either dies at once; or another Distemper succeeds, more troublesome and incurable than the first. Should it be expelled to some outward part, the Danger indeed is less; and as soon as ever such a Tumour appears, ripening Pultices should be apply'd to bring it to a Head, after which it should immediately be opened.

Sec. 61. In order to prevent such unhappy Consequences, great Care must be taken, whenever such terrifying Symptoms come on, [about the Time of the Crisis] to make no Change in the Diet, nor in the Treatment of the Patient; except in giving him the loosening Glyster No. 5; and applying every two Hours a Flannel, squeezed out of warm Water, which may cover all the Belly, and in a Manner go round the Body behind the Reins. The Quantity of his Drink may also be increased a little; and that of his Nourishment lessened, as long as this high and violent State continues.

Sec. 62. I have not spoken of Vomits or Purges, as being directly contrary to the Nature of this Disease. Anodynes, or Opiates, to procure Sleep are also, in general, very improper. In a few Cases, however, they may possibly be useful; but these Cases are so very difficult to be sufficiently distinguished, that Opiates should never be admitted in this Disease, without the Presence and Advice of a Physician. I have seen many Patients, who have been thrown into an incurable Hectic, by taking them improperly. When the Disease is not received in a mortal Degree, nor has been injudiciously treated, and proceeds in a benign regular Manner, the Patient may be called very well and safe by the fourteenth Day; when he may, if he has an Appetite, be put upon the Diet of People who are recovering. But if he still retains an Aversion to Food; if his Mouth is foul and furred, and he is sensible of some Heaviness in his Head, he should take the purging Potion No. 11.

Sec. 63. Bleedings from the Nose occur sometimes naturally in this Disease, even after repeated Bleedings by Art; these are very benign and favourable, and are commonly attended with more Ease and Relief than artificial Bleedings. Such voluntary Discharges may sometimes be expected, when the Patient is sensibly mended in many Respects after the Use of the Lancet; and yet complains of a great Pain in his Head, accompanied with quick sparkling Eyes, and a Redness of the Nose. Nothing should be done to stop these voluntary Bleedings, since it would be very dangerous: For when Nature has fulfilled her Intention by them, they cease of themselves. At other times, but more rarely, the Distemper is carried off by a natural Purging, attended with moderate Pain, and the Discharge of bilious Matter.

Sec. 64. If the Expectoration, or hawking up of Matter, stops very suddenly, and is not speedily attended with some other Evacuation; the Oppression and Anguish of the Patient immediately return, and the Danger is great and pressing. If the Distemper, at this Juncture, is not of many Days standing; if the Patient is a strong Person; if he has not as yet been plentifully bled; if there be still some Blood mixed with the Humour he expectorates; or if the Pulse be strong and hard, he should be bled immediately in the Arm; and constantly receive the Steam of hot Water and Vinegar by the Mouth, and drink plentifully of the Ptisan No. 2, something hotter than ordinary. But if his Circumstances, after this Suppression, are different from these just mentioned; instead of bleeding him, two Blisters should be applied to the Legs; and he should drink plentifully of the Ptisan No. 12.

The Causes which oftenest produce this Suppression of his Expectoration are, 1, a sharp and sudden cold Air. 2, too hot a one. 3, over hot Medicines. 4, excessive Sweating. 5, a Purge prematurely and injudiciously timed. and 6, some immoderate Passion of the Mind.

Sec. 65. When the Sick has not been sufficiently bled, or not soon enough; and even sometimes, which I have seen, when he has been greatly weakened by excessive Bleeding; so that the Discharges by Stool, Urine, Expectoration and Perspiration, have not been sufficiently made; when these Discharges have been confused by some other Cause; or the Disease has been injudiciously treated; then the Vessels that have been inflamed, do not unload themselves of the Humours, which stuff up and oppress them: but there happens in the Substance of the affected Lung, the same Circumstance we see daily occur on the Surface of the Body. If an inflammatory Tumour or Swelling does not disperse itself, and disappears insensibly, it forms an Imposthume or Abscess. Thus exactly also in the inflamed Lung, if the Inflammation is not dissipated, it forms an Abscess, which, in that part, is called a Vomica: and the Matter of that Abscess, like the external ones, remains often long inclosed in its Sac or Bag, without bursting open its Membrane or Case, and discharging the Matter it contains.

Sec. 66. If the Inflammation was not very deeply seated in the inward Substance of the diseased Lung; but was extended to its Surface, that is, very near the Ribs, the Sac will burst on the Surface of the Lung; and the Matter contained in it must be discharged into the Cavity, or Hollowness of the Breast, between the Lung, the Ribs, and the Diaphragm or Midriff, which is the Membrane that divides the Breast and the Belly. But when the Inflammation is considerably deeper, the Imposthume bursts withinside of the Lung itself. If its Orifice, or Opening is so small, that but little can get out at once; if the Quantity of all the Matter be inconsiderable, and the Patient is at the same Time pretty strong, he coughs up the Matter, and is very sensibly relieved. But if this Vomica be large, or if its Orifice is wide, and it throws out a great Quantity of Matter at once; or if the Patient is very weak, he dies the Moment it bursts, and that sometimes when it is least expected. I have seen one Patient so circumstanced expire, as he was conveying a Spoonful of Soup to his Mouth; and another, while he was wiping his Nose. There was no present Symptom in either of these Cases, whence a Physician might suppose them likelier to die at that Instant, than for some Hours before. The Pus, or Matter, is commonly discharged through the Mouth after Death, and the Bodies very soon become putrified.

Sec. 67. We call that Vomica which is not burst, an occult or hidden, and that which is, an evident or open one. It is of considerable Importance to treat exactly and clearly of this Topic; as a great Number of Country People die of these Imposthumes, even without a Suspicion of the Cause of their Death. I had an Instance of it some Days since, in the School-master of a Village. He had an occult and very considerable Vomica in the left Lung, which was the Consequence of an Inflammation of the Breast, that had been treated improperly at the Beginning. He seemed to me not likely to live twenty four Hours; and really died in the Night, after inexpressible Anguish.

Sec. 68. Whatever Distemper is included within the Breast of a living Patient, is neither an Object of the Sight or Touch whence these Vomicas, these inward Tumours, are so often unknown, and indeed unsuspected. The Evacuations that were necessary for the Cure, or sometimes for the Prevention, of them, have not taken place, during the first fourteen Days. At the End of this Term, the Patient, far from being cured, is not very considerably relieved; but, on the contrary, the Fever continues to be pretty high, with a Pulse continually quick; in general soft and weak; though sometimes pretty hard, and often fluctuating, or, as it were, waving. His Breathing is still difficult and oppressed; with small cold Shudderings from Time to Time; an Exasperation of the Fever; flushed Cheeks, dry Lips, and Thirst.

The Increase of these Symptoms declare, that Pus or Matter is thoroughly formed: the Cough then becomes more continual; being exasperated with the least Motion; or as soon as ever the Patient has taken any Nourishment. He can repose only on the Side affected. It often happens indeed, that he cannot lie down at all; but is obliged to be set up all Day; sometimes even without daring to lean a little upon his Loins, for fear of increasing the Cough and Oppression. He is unable to sleep; has a continual Fever, and his Pulse frequently intermits.

The Fever is not only heightened every Evening; but the smallest Quantity of Food, the gentlest Motion, a little Coughing, the lightest Agitation of the Mind, a little more than usual Heat in the Chamber, Soup either a little too strong, or a little too salt, increase the Quickness of his Pulse the Moment they occur, or are given. He is quite restless, has some short Attacks of the most terrible Anguish, accompanied and succeeded by Sweatings on his Breast, and from his whole Countenance. He sweats sometimes the whole Night; his Urine is reddish, now frothy, and at other times oily, as it were. Sudden Flushings, hot as Flames, rise into his whole Visage. The greater Number of the Sick are commonly sensible of a most disagreeable Taste in their Mouth; some of old strong Cheese; others of rotten Eggs; and others again of stinking Meat, and fall greatly away. The Thirst of some is unquenchable; their Mouths and Lips are parched; their Voice weak and hoarse; their Eyes hollow, with a kind of Wildness in their Looks. They have a general Disgust to all Food; and if they should ask for some particular Nourishment without seeing it, they reject it the Moment it is brought them; and their Strength at length seems wholly exhausted.

Besides these Symptoms, a little Inflation, or Bloatedness, as it were, is sometimes observed on the Breast, towards the Side affected; with an almost insensible Change of Colour. If the Vomica be situated at the Bottom of the affected Lobe of the Lungs, and in its internal Part, that is, nearly in the Middle of the Breast, some Puffiness or light Swelling may be perceived in some Bodies, by gently pressing the Pit of the Stomach; especially when the Patient coughs. In short, according to the Observations of a German Physician, if one strike the open Hand on the Breast, covered only with a Shirt, it retains in the Spot, which is directly opposite to the Vomica, a flat heavy Sound, as if one struck a Piece of Flesh; while in striking on the other Side it gives a clear loud Sound, as from a Drum. I still doubt however, whether this Observation will generally hold true; and it would be hazardous to affirm there is no Abscess in a Breast, which does not return this heavy Sound.

Sec. 69. When a Vomica is formed, as long as it is not emptied, all the Symptoms I have already enumerated increase, and the Vomica grows in Size: the whole Side of the Lung affected sometimes becomes a Bag or Sac of Matter. The sound Side is compressed; and the Patient dies after dreadful Anguish, with the Lung full of Pus, and without having ever brought up any.

To avoid such fatal Consequences, it is necessary to procure the Rupture and Discharge of this inward Abscess, as soon as we are certain of its Existence: And as it is safer it should break within the Lobe affected, from whence it may be discharged by hawking up; than that it should burst and void itself into the Cavity of the Breast, for Reasons I shall give hereafter, we must endeavour, that this Rupture may be effected within the internal Substance of the Lungs.

Sec. 70. The most effectual Methods to procure this are, 1. To make the Patient continually receive, by his Mouth, the Vapour of warm Water. 2. When by this Means that part of the Sac or Abscess is softened, where we could wish the Rupture of it to happen, the Patient is to swallow a large Quantity of the most emollient Liquid; such as Barley Water, Almond Milk, light Veal Broth, or Milk and Water. By this Means the Stomach is kept always full: so that the Resistance to the Lungs being considerable on that Side, the Abscess and its Contents will naturally be pressed towards the Side of the Wind-pipe, as it will meet with less Resistance there. This fulness of the Stomach will also incline the Patient to cough, which may concur to produce a good Event. Hence, 3, we should endeavour to make the Patient cough, by making him smell to some Vinegar, or even snuff up a little; or by injecting into his Throat, by the Means of a small Syringe or Pipe, such as Children make out of short Pieces of Elder-Boughs, a little Water or Vinegar. 4. He should be advised to bawl out aloud, to read loud, or to laugh heartily; all which Means contribute to burst open the Abscess, as well as those two following ones. 5. Let him take every two Hours a Soup-Ladle of the Potion No. 8. 6. He should be put into a Cart, or some other Carriage; but not before he has drank plentifully of such Liquors as I have just mentioned: after which the Shaking and Jolting in the Carriage have sometimes immediately procured that Rupture, or breaking of the Bag or Abscess, we wished for.