f**ty&T*J ^D-OO^'COi > Lfvfi Surgeon General's Office 'ec'ion, N< fe'AG^:j^-::i^3Clo.g^r.;.^oaQ\^g'^c :.q MEDICAL REPORTS, ON THE EFFECTS OF WATER, COLD AND WARM, AS A REMEDY IN FEVER AND OTHER DISEASES, Whether applied to the Surface of the Bodj/tjt»msid^ntcrnallj/. VOL. I. ,./"' Including an Inquiry into the Circumstance%/4'hg|0p€3sAer Cold Drink, or the Cold Bath, dangerous in Hearth. ° To which are added, Observations on the Nature of Fever;—and on the EffeCts of Opium, Alcohol, and Inanition. VOL. II. Consisting of the Author's Experience of this Remedy subsequent to the second Edition of Volume I. And of important Com- munications from others on the same Subject. To which are added, Four Letters;—One on the Sphere of Febrile Conta- gion ;—Two on the Establishment of a Lunatic Asylum in Li- verpool ;—and One on the Effects of Nitrous Acid in Lues Venerea. BY JAMES CURRIE, M.D..F.R.S. Fellow of the Royal College of Pbyfcians, Edinburgh. Intentiones operationum, quas propofuimus (ut arbitramur) veriffimte funt, remedia inten- tionibus fida. * * * Rem ipfam txpermentum et comprobavit it promo-veb'iU * * * Opera eonfilii cujufque prudentioris, Junt effeSiu admiranda, ordine quoque egregia, modis faciendi tanquam Bulgaria, Bacon. Hiftoria vitae et mortis. FROM THE FOURTH LONDON EDITION, CORRECTED AND ENLARGED. PHILADELPHIA PRINTED : FOR JAMES HUMPHREYS, AND FOR BENJAMIN AND THOMAS KITE. 1808, -r* ■» r\ T.—"V..7"-. '•'/njrrton w> TO THE RIGHT HONOURABLE SIR JOSEPH BANKS, Baronet, and Knight of the Bath, President of the Royal Society, tyc. &c. cjrY. Sir, IN presenting this volume to you, I beg leave to say a few words on the views with which it was written, and the circumstances that gave rise to the publication. About eighteen years ago, when I was at Edinburgh, it fell to my lot to write a paper on the influence of cold on the living bo- dy, for one of the societies of students, of which I was a mem- ber. In defending my speculations against some ingenious oppo- nents, a perpetual contradiction occurred as to fads, which a re- ference to original authorities, did not enable me to remove; fof I discovered, that the accounts given of the temperature of the human body under disease, even by the most approved authors, are, with a few exceptions, founded, not on any exact measure- ment of heat, but on the sensations of the patient himself, or his attendants. Impressed with the belief, that till more accurate information should be obtained respecting the actual temperature in different circumstances of health, and disease, no permanent theory of vi- tal motion could be established, nor any certain progress made in the treatment of those diseases in which the temperature is dimin- ished or increased. I have occasionally since that time, observed and recorded such fafts as related to the subject ; intending, one day or other, to lay my observations before the public, if they acquired an importance that deserved attention. In the outset of this undertaking, nothing seemed wanting but accurate thermo- meters, and a moderate portion of time and attention ; and I em- braced in imagination the whole eft-efts of temperature upon health IV and disease ;—a range of inquiry which experience has convinced me it would be temerity and folly to hope to go through. In this general view of the subject, some valuable communications have however been made to me by my much respected friend Dr. Per- cival ; which do not apply to the particulars treated of in the fol- lowing volumes, but which I am not without the hopes of specify- ing at some future period, when I may have occasion to employ them. Though I have some time seen, that the delay of publishing till my original plan was executed, was likely to render my la- bours wholly abortive, or to convert the imperfect product from a gift into a legacy ; yet I should not have given to the world so detached and unfinished a work as the present, according to the views I had originally entertained, but for the circumstances I am about to relate. By the accounts received at the beginning of the present year, the fever of the West Indies appeared to continue its desolating progress with little abatement, and in America to be beginning Its ravages anew.—With this pestilence, science seemed hitherto to have contended; in a great measure, in vain, and new methods of opposing it, were not merely justifiable, but requisite. At this time an account of the success of the nitric acid in Lues Venerea and Hepatitis, as employed by your correspondent Mr. Scott, of Bengal, was, through your means, given to the public. His the- ory, suggested by the new chymistry, did not appear promising ; but it was neither wise nor candid to reject his experience on that account. The first trials which I made of his practice persuaded me, that, though the success of the nitric acid might have been exaggerated by a warm imagination and a benevolent heart, it as- suredly did succeed in certain cases of the diseases in question, and that a remedy of considerable power and of perfeel safety^ was intro- duced into medicine. These opinions subsequent experience has served to confirm. In the fever of the West Indies mercury had been much employed, and though different notions were enter- tained of its mode of operation, it seemed on the whole the most approved remedy. Since the nitric acid appeared to be a substi-' tute for mercury in other cases, it seemed reasonable to try its ef- fects in this fatal fever. I suggested this practice by letter to some practitioners in the West Indies, and I submitted my notions on the subject to you ; sensible that your character and station might bring that into immediate notice, which the influence of a private individual could but slowly efFeCt.—Whatever difference there might be in some of our opinions, I was confident there was none V in our wishes for alleviating human misery, and mitigating the destruction of this desolating war. Your conduct even exceeded my expectation. Our correspondence on this occasion turned my views to the other means of opposing this pestilence. Ablution with cold water in fever had been so long employed at the hospital here, and in private practice, by my friends and colleagues Dr. Brandreth and Dr. Gerard, as well as myself, that it was become general in Li- verpool, and common in the county of Lancaster. So long ago as the year 1791, a general statement by Dr. Brandreth of its advan- tages had been published by Dr. Duncan, in the medical Commen- taries of that year. It had also been noticed by me in the Philo- sophical Transactions for 1792, and I had repeatedly mentioned it in private correspondence; it had often been recommended to the surgeons of African ships in those examinations required by the legislature, and which are chiefly made by the physicians and surgeons of our hospital. On different occasions likewise I had not only explained, but exhibited the practice, to practitioners from a distance, and particularly to one or two going to the West Indies. A method of treatment so bold, and so contrary to com- mon prejudices, made however, as it appears, slow progress. The mode of operation of our remedy has been misapprehended; the proper period for using it has not been understood; and on some occasions having been resorted to improperly, the consequences have brought it into disrepute. Reflecting on these circumstan- ces, and exposed by situation to the reiterated sounds of death from the Western world, my decision was speedily made: I re- solved no longer to delay an account of our treatment of fever, in the expectation of including it in a larger field of discussion, and of presenting it in a form more conducive to reputation ; and the fruit of this determination is the work now presented to you. In treating my subjects, perspicuity has been studied rather than ri- gorous method ; I have every where endeavoured to make my steps so plain, that they may be distinctly traced ; the most important points are impressed again and again to guard against mistake; my thermometrical observations have enabled me to give a preci- sion to the directions for the use of the affusion of cold water which otherwise they could not have had; and, if I do not flat- ter myself, have laid a foundation for my reasonings, which spe- culations on fever have seldom possessed. I have guarded against the unnecessary use of technical as well as of general expressions. It were better perhaps that medicine, like other branches of na- tural knowledge, were brought from its hiding-place, and exhi- bited in the simplicity of science, and the nakedness of truth. K VI it had been in my choice, I would not have adopted the language of theory, like Boerhaave, or Sydenham ; but have exhibited a medical work in the phraseology that Bacon, had he lived in our days might have used. Unfortunately in the present state at me- dical knowledge, wholly to avoid the language of theory is im- possible The corruptions of false doarines must remain more or less, in our phraseology, after the doctrines themselves are ex- ploded ; since custom has rendered the expressions in which they are found, intelligible, and human sagacity has not yet discovered those first principles of living motion, by which the doarines and the language of physiology might at once be reformed. Hence the term re-aBion is applied to certain motions of life, though in a sense very different from that in which it is used in the science of inanimate motion from which it is borrowed ; and such words as tone will still be found in the following pages, though the theory that introduced them into medicine be universally abandoned. The use of such expressions is however an evil, justified only by necessity ; and I have endeavoured to avoid it as much as lay in my power. Possibly this notice may procure me some readers among men of general science; and this I confess to be one of my objeas in dedicating the work to you. It is naturally an author's wish that his book may be read by those who can appreciate it, and who from their situations may have it in their power to bring its pre- cepts into praaice. In both these points of view I appeal to you— to your scientific knowledge, and to your generous heart. The work that I address to you is in a great measure praaical. A man of genius, at the head of a fleet or army, would probably find lit- tle difficulty in understanding it; and possibly, if he understood it, there might be occasions on which it would afford scope to his humanity and patriotism. But whatever be its fate with men pro- fessedly military, I trust it will not be overlooked by the medical praaitioners of our fleets and armies ; a most meritorious class of the profession, to whom a great part of the improvements in the modern praaice of medicine is to be ascribed. Conceiving that the circulation of this volume, as well as its usefulness, might be extended by connecting the history of the af- fusion of cold water in fever, with other views of the same reme- dy, and with a few observations on the other remedies in fever, I have entered upon these points, without any very stria regard to method ; and have been insensibly led to speak of some of the operations of temperature on the body in health, a subjea which I had reserved. Such as it is, this volume may s«rve as the first of Vll a series on similar subjeas, if I should ever write them; and it may I hope, stand alone, if f should write no more. I am sensible that some of these particulars would have appear- ed with more propriety in a professed preface ; but having enter- ed on certain explanations in my address to you, I have given the whole of these preliminary observations in the same form ; a free- dom that I trust you will forgive. I cannot conclude without declaring the sense I entertain of your candour and politeness. Accept the tribute of my respea.—May you live long to cultivate and protea the sciences—the sciences, whose utility is beyond dispute ; whose progress is superior to ob- struaion; and which, of all the possessions of man, seem least to partake of the imperfection of his nature ! I have the honour to be, Sir, Your faithful and very obedient Servant, JAMES currie;. Liverpool, 31st Oclober, 1797. ADVERTISEMENT TO THE THIRD EDITION. AN Apology is perhaps required for the delay which has occur- red in presenting the third edition of this work to the Public, and especially to those Gentlemen by whose communications it is en- riched. The immediate pressure of my professional duties, and an im- perfecJ state of health, have occasioned this delay. These circumstan- ces must also plead my excuse for the work being printed with less accuracy than could be wished, and without the advantage of a new arrangement, which it was once my intention to have given it. But the copious Table of Contents and Index, will in some measure sup- ply this defecl. J. C. CONTENTS OF VOLUME I, C H a p . I. Narrative of Dr. Wright. In a voyage from Jamaica to Liverpool, he employed afFufion of cold water in fever, 17 Chap. IL Hiftory of a fever -which broke out in the Liverpool Infirmary. The afFufion of cold water firft pra&ifed in this fever by the author, Decemb. 1787, 21 Chap. III. Hiftory of a fever •which occurred in the $otb Regiment. How produced, - - - - - 23 Situation and fy.nptoms of the fick, - - - -24 The progrefs of the infection how flopped, » - » - 25 In what fituations this practice may be imitated, - 26 Chap. IV. The manner in ivhicb the affufion of did water Jbiuld be uftd in fever. The kihd of fever in which it is to be ufed, 27 The time and manner of ufing it, ... - 28 Not to be ufed in the cold ftage, nor when the heat is below what is naturaf, nor in the fweating ftage, - - - - 49 Chap. V. Cafes in ivhicb the affufion of cold "water ivas ufed in different ftages of fever. Seven cafes detailed. - - - - - 31 Convparifon of the advantages attending the afFufion of cold water at different periods of fevr, * »■ *. - « 38 Case VIII. The cold afFufion ufed in intermittent fever, - - ib. Chap. VI. General observations. Patients fubmit to the cold afFufion when once experienced, readily, • 40 Different kinds of water ufed, - ib. Water of the Merfey, not falter at high than at low water, - - ib. Thermometers defcribed, - - - - 41 Chap. VII. Precautions requifite in ufing the cold affufion. Illuftrated by cafes, - - - 43 Chap. VIII. General remarks on fever. Hiftory of a cafe of fever in which the cold afFufion was not falutary, - 48 A fpeties of fever detailed, neither fynochus nor typhus, - 49 The cold afFufion not to be ufed when the extremities feel cold, whatever may be the heat of the central parts, - - - - 51 Chap. IX. Of the affufion of cold "water and tepid water in fmall-pox, &c. Case I. AfFufion of colJ water fuccefsful in eruptive fever, - 53 Case 11. Unfuccefsful in the after ftages, ... 54 Speculations on fmall-pox, - - - ... 56 Account of inoculation with matter more and lefs recent, - - 59 Ufe of the cold afFufion in fcarlet feve-, - - 61 Dr. Cullen's opinion on fmall-pox controverted, - - - 62 Operation of the cold afFufion explained, - - - 63 Chap. X. Of the affufion of tepid water on the surface of the body in feverijh diJorders\ and offpongir.g the body •with vjater or vinegar. Degn: ■>' heat t.> which the term tepid is applied, . - » 64 i" to which the term cool is applied, - - -67 Te id afFufion ver/ cooling, but not fo permanent in its effects as the cold afFufion 65 Sponging or wetting the furfoce, ... - 66 Difcremon on general action of cold, with remarks on Drs. Brown and Darwin, (note) 67 AfFufion of cold water practifed in a fever at Breflaw in Silefia, in the year 1737, with an aoftracl froori Dc Hahn, - - • 69 Tepid or warm bath, how ufed by the Grrcks in the heroic ages, - 74 2 X Ch.&• When opium produces fleep, .... 198 How and when to be administered in fever, - - - 199 General view of the operation of alcohols, ... 200 How and when to be administered in fever, ... 202 Note refpecting,the ufe of cold in inflammatory fevers, &c. - - 20J Chap. XIX. Is there an inhalation by the fkin ? Inhalation by the fkin univerfally believed by the ancients, and generally affented to in our own times, - - - - 205 Experiments that render it improbable, ... 206 Cafe of Mr. M. whom it was attempted to nourifh by inhalation, - 207 Reflections on this cafe, - - - - -215 Cafe of Mr. J. who died of inanition, (note) ... ib. Experiments of Mr. Seguin on the inhalation of the fkin, referred to - 218 Phenomena fuppofed to depend on this abforption, differently explained, 219 Theory of Dr. Rutherford on Diabetes, ... 221 Quotation from M. Fourcroy's report on M. Seguin's experiments, - 222 Experiments on Inhalation of the furface by Dr. Rouffeau of Hifpaniola - 227 Chap. XX. Population of Liverpool—Prevalence of fever among) the poor. Population of Liverpool in 1789, and 1801, - - 230 General table of difeafes entered on the books of the Difpenfary for feventeen years, with the comparative healthinefs of the different months, • 233 General table of fevers for feventeen years, Sec. - - 236 Note on the ignorance and inattention of the poor to the bcft means of nutrition, 239 Account of the Houfe of Recovery at Manchester, - - ib. Hiftory of the receptacles for fever at Liverpool, - - - 241 Hiftory of the Liverpool Houfe of Recovery, t• • - # 245 Application of the Corporation of Liverpool to the Phyficians, on the means of preferving the health of the town, with extracts from their anfwer, - 246 CONTENTS OF VOLUME II. Chap. I. The author's more recent experience of the ufe of the cold and tcp':d affufion.—Ufe of the Digitalis Purpurea in inflammatory Feven. General obfervations, - - - - - 25. Cafes in illustration of thefe, ...... 256 Cafe illuftrating the effects of the wind blowing over the naked body of a patient in fever, - - - ... 258 Dr. Jackfon and M. Defgenettes quoted, - - ." . . 259 General remarks on the ficklinefs of Liverpool in iSox, and the prevailing difeafes, 261 Cafes in which the cold and tepid afFufion did not fucceeu, - - 26c Remarkable cafes communicated by Mr. Dalrymple of Norwich, - 268 Ufe of the Digitalis Purpurea in the Phlegmafiae and Hemorrhagic, ' - 271 Combined ufe of the Digitalis and Mercury in confunv>do.T. (no''?) - ib xn Chap. II. Thefubjeff continued. Remarks on Scarlatina from different writers, - - 275 Remarks by the author, with his practice in this difeafe, - .276 Cafes of confluent Small-pox ending fatally, - - 285 Communications from Dr. Gregory on Scarlatina, - - - 287 Application of the cold afFufion to Cynanche Tonfillaris, - - 295 » . . Influenza, - ■» ib. Effect of the warm affufion in a cafe where laudanum was fwallow«d by miftake, 296 Chap. III. Communications to the Author refpeiling the ufe of the cold and tepid affufion in diffe ent parts of Great Britain. Ufe of the cold affufion, by Dr. Dimfdale, ... 299 Gregory of Edinburgh, - - 304 Dr. Reeve's account o/its ufe in the clinical wards by Dr» J. Home, - ib. Communication from Dr. Bree of Birmingham, ... 306 Ufe of the cold afFufion by Mr. Marfhall, ... 310 ■ by Dr. Reid, London, - - - 3X4 .by Dr. Scott, Ifle of Man, - - - ib. Chap. IV. Some account of the ufe of the cold affufion in Fevers on ship-board. Uf of the cold affufion by Mr. Wilfon of the Huffar, - - 3l6 Ufe of the cold lavation by Dr. Trotter, phyfician to the fleet, - - 317 Ufe of the cold affufion by Mr. Farquhar of the Tartar, - - ib. Ufe of the cold affufion by Mr. Magrathof theRuffel, - - 3*8 Account of the fever on board the Aftaeon, ... 320 Communication from Dr. Carfon, .... 322 Ufe of the cold affufion by Mr. Simplon of the Naiad, - - 313 ■ by Mr, Nagle of the Ganges, - - 3*4 ' -----—by Dr, Baeta of Lilbon, ... 331 ■- . 1 'by Dr. Gomez, phyfician to the Portuguefe fleet, 332 Chap. V. Some account of the ufe of the cold affufion on jhore in, the -warmer cfalKtei. Ufe of the cold afFufion in Minorca by Mr. Dewar, - - 340 ■ ' ■ ■ .1 in Egypt, - - - 344 Communication from Mr. M'Gregor, fuperintendant fuigeon of General Baird's army there, - - . - - -345 The cafe of Sir John Chardin in Perfia, - - - 347 Quotations from Biuce on the ufe of the cold affufion in Abyflinia, - 352 Dr. M'Lean's account of the ufe of the cold bath in two cafes of fever in India, 353 ■ ' ■ ■ in the fever of St. Domingo, ... 354 Dr. Jackfon's ufe of the cold bath there, . . . « 355 Ufe of the cold affufion by Dr. 0»de in Demarary, . . . 358 ■ ' - —.Dr. Chifholm, . . . 360 111 ■» Dr, Macneill, in Guiana, . • 361 Ule i-if the col affufl n by Dr. Robertfonin Barbadoes, . . 365 1 ...... 11 Dr. Davidson in St. Vincents, . . 367 Account of its introduction at Philadelphia by Dr. Stevens, with remarks, 370 Ufe of the cold affufion by Drs. Selden and Whitehead, of Virginia, . 373 Conclusion—Communications with Dr, Wright, . . 377-378 Chap. VI. Additional information refpeiling the ufe of the cold and tepid affufion of -water in fever, fince May, 1804, . . Communications from Dr. Barry and Dr. Daly of Cork, . , 385 Hiftory of a fever among the French prifoners at Stapleton, . . 387 ■ 1 . n ■---in the Horfe-Guards at Canterbury, . , 393 Some particulars of the fatal epidemic at Gibraltar, ... 306 Notice of a fever in the Suffex Militia at Chelmsford, , . 404 Concluding observations, . . . . .403 APPENDIX. Letter to Dr. Clark, on the propriety of annexing Fever-Wards to general hofpitals, 407 Two letters on the establishment of a Lunatic Afylum at Liverpool, 414 Letter to Dr. Beddocs on the Nitric Acid, 4^6 xiii INDEX TO THE FIRST VOLUME. A ABLUTION of the body with cold water, its ufe in fever, -' - 1% employed by De Hahn, in the fever of Breflaw, 1737, 69 Affufion of cold water on the furface of the body ufed by Dr. Wright, - 17 employed in a fever in the Liverpool Infirmary, 21 employed in a fever in the 30th regiment, - 23 --------- manner of ufing it in fever with cafes, - - .28 ------------------ufed with different impregnations, ... 40 --------- precautions required in ufing it, illustrated by cafes, - - 43 --------- cafe of fever in which it was not falutary, - - 49 ufed in fmall-pox, - - - - - 53 Scarlatina anginofa, . - - 60 Affufion, temperature of the water employed, - - - - *>3 its effects in fever explained, - - - - - 177 ■---------various accounts of its fuccefs in fevers on fhip-board, - • 182 AfFufion of tepid water on the furface of the body, its cooling effefts, - - 64 11 1 how and when to be employed, ... 64 not fo effectual in fever as the affufion of cold water, 65 this explained, - - - - 179 Alexander the Great, fuffetings of his army from imprudent drinking of cold water, 84 his own illnefs from bathing in the Cydnus, explained, 91 Alcohol, observations on its. effects in health and difeafe, - - - . 200 Antimonials, their effects explained, .... 197 B Bath, cold, fome account of its ufe in fmall-pox, - 59 ufed by Galen in fever, - - - _ _ 85 ————-— when fafe, in health and difeafe, ... 90 ---------— cafes and hiftories illuftrating this, - - - 9s ——— ufe of it in convulfive difeafes, .... 105 cafe of infanity in which it was fuccefsful, - - - 134 ~——— precautions neceffary in employing it in infanity or convulfions, - 138 ————— propofed to be employed in fever of the Weft Indies, and in the plague, 183 Bath, warm, ufed in infanity, - - - - - 135 ———— ufe of, propofed to he revived in the Weft Indies, - - *94 ——— its reftorative effedts after fatigue, - - - - 194 ■■— general obfervations on it, - - - - - - J95 Baths, Ruffian, their temperature, - - - - - 101 —- ancient, obfervations on. - - - • - J°2 c Cold, its Stimulant powers afferted and explained, ■ ■ external, dangerous after profufe fweating, ii its operation in inflammatory difeafes, Convulfive difeafes, cafes of, with various remedies, Cydnus, river, account of, D Diet of the poor, remarks on z39 Digitalis ufed in infanity, - 335 67 - 193 203 106 95 XIV E Emetics, their operation in fever explained, - *97 Evaporation, fuppofed to regulate the animal heat. - - 189 F Fever, hiftories of, .... - 17*197 cafes of, detailed, - - - • -31 ■ remarks on the nofological arrangements of, - - 48 cafe of, not included in thefe, - - - - 49 ■ hectic, remarks on, - - - - 65 ■■ theories of, ancient and modern, - - 162 H Heat, animal, ftate of in fever, cafes which fhew this, - 31 ——————— method of examining, - - . 41 ' hiftory of the changes of, in the paroxyfm of fever, - 172 ■ its origin, .... 184 —---------how regulated, .... 186 Hydrophobia not an inflammatory difeafe, - - 133 ———— diftinct in its nature from tetanus. - - - 133 I Immerfion in water fait and frefh, cold and warm, experiments on, - 145 Inanition, cafes of, - - - . . 207 Inhalation by the fkin, generally believed by the ancients, . - - 187 ———————— afferted by Haller, and the moderns in general, 205 ■ experiments which render it doubtful, - 206 ■ denied by Seguin, - - - - 219 ' — extract of an account of his experiments refpedting it, 522 ■ ■ ■ experiments of Dr. Rouffeau which difprove it, 227 Intoxication, Angular method of recovery from, ... 201 Inunction of the furface of the body mentioned by Homer, - - 74 ■ the ufe of by the Romans, - - 93 —————^— general among the ancients, - - "93 L Liverpool, population of, with remarks, ... 230 —————prevalence of fever among the poor, - . - 231 ■ charitable eftabliShments, account of, - - 232 ——----comparative ficklinefs of the different months among the poor, 234 ——— houfe of recovery, hiftory of the ... 24c M Mania, remarkable cafe of, cured - 154 Maniacs, their refiftance of cold and contagion, - . - 139 Merfey river at Liverpool, not falter at high than low water, - - 40 Miffiffippi river, waters never injurious to thofe who drink them, and why, 98 o Opium, ufed in a cafe of infanity, - - - - 714 operation of in fever and in health, remarks, on, - «■ iq8 P Perfpiration, infenfible, its effedts in cooling the body, - - 187 - more plentiful in warm than cold weather, - . 188 ——— quantity of, . . j£, ■ Senfible, remarks on, .... I(,0 ■ matter of in the European, not fitted to the torrid zone . 19- Plague, cured by immerfipn in the fea - - . 183 R Respiration, modern theory of - , - . - j8r XV s Shipwreck, remarkable hiftory of, with an account of its effedts on the mariners, 140 Small-pox, obfervations and experiments refpecting, 58 ^Springs, temperature of in different climates - - "97 T Tetanus, cafes of, - - - - - 106 Two new cafes of, treated fuccefsfully ... 127 Thermometers, account of - - . 41 —————— how to be applied in taking the human heat, - 41.160 Thirft, nature of, 178 Thirft, obfervations on the relief obtained in, by the affufion of water, or im- merfion in the bath, .... 178.219; Tobacco, its ufe in convulfive difeafe .... 123 w Water, cold, ufed as a drink in fever by the ancients, - 69 ■ authorities for this practice, • - - - 75 - againft it, - - - .76 » rules for ufing it in fever, 78 ■ ■ 1 in health - 79 ■ cafes illuftrating the circumstances under which cold drink is dangerous, - - - - - 81 ■ cafe of convulfions cured by it, ... J26 ■ how to be ufed in fever of the Weft Indies, and in plague, 181 ---m® INDEX TO THE SECOND VOLUME. A Adtaeon, receiving Ship at Liverpool, fever on board of her extends to the channel fleet, - - - - - 320 Affufion of cold water, cafes in which it was lefs fuccefsful than ufual, - 263 remarkable inftance of its fuccefs communicated by Mr. Dal- rymple of Norwich, ..... 268 communications to the author refpecting its fuccefs in different parts of Great Britain, - - - - 298 ■ various accounts of its fuccefs in fevers on fhip-board, 3H-354 various accounts of its fuccefs in fevers on Shore in the warmer climates, .... - 340 ■ ■ -unfuccefsful at Philadelphia, as communicated by Dr. Stevens, 370 Affufion of tepid water ufed by the author in certain cafes of typhus, . 265 Affufion of warm water, remarkable cafe of the effedts of, . • 296 Antimonials, their effects explained, ... 367, 382 c Contagion, febrile, fphere of, letter to Dr. Clark respecting, • • 4°7 D Digitalis ufed in the inflammatory difeafes, . • » 273 Dyfentery, epidemic, in Liverpool, account of, • • • 261 XVI F Fever, hiftory of, • • • » ' cafes of, detailed, . i. fcarlet, cured by affufion of cold water, ■ i remarks on, ... - G Gomez, Dr. Bernadino Antonio, his account of the extraordinary fuccefs of the cold affufion and lavation, on board the Portuguefe fleet. I Influenza, ufe of tepid afFufion in, ♦ • ---------1 ufe of cold affufion in . • • L Liverpool, Lunatic Afylum at, letters refpedting, • • • N Nitric acid, its effeas in Syphilis, letter to Dr. Beddoes refpecting, P Perfian phyficians, their practice in dyfentery, . • ' • i--------- - their practice in fever, • Plague, cafes of, cured by expofure naked to the dews of night, ——— cold drink, and the cold bath recommended in, 'cured by immerfion in the Nile, - • • —— treated fuccefsfully by fponging the furface with vinegar, &c. s Small-pox, cafes of, treated by the affufion of cold and warm water, w Water, how ufed by the Egyptians in their burning fever, in Nubia and Abyflinia, .... MEDICAL REPORTS, &c. CHAPTER I. ® Narrative of Dr. Wright. IN the London Medical Journal for the year 1786, Dr„ William Wright,* formerly of the ifland of Jamaica, gave an account of the fuccefsful treatment of fome cafes of fever by the ablution of the patient with cold water. " On the ift of Auguft, 1777/' fays Dr. Wright, u I embarked in a (hip bound to Liverpool, and failed the fame evening from Montego Bay. The mailer told me he had hired feveral failors on the fame day we took our departure; one of whom had been at fick quarters on more, and was now but in a convalefcent ftate., On the 23d of Auguft we were in the laticude of Bermudas, and had had a very heavy gale of wind for three days, when the abovementioned man relapfed, and had a fever, with fymptoms of the greateft malignity. I attended this perfon often, but could not prevail with -him to be removed from a dark and confined fituation, * Now Prefident of ill* College of Phyficians. Edinburgh, (tSo/j.) i8 to a more airy and convenient part of the (hip; and as he refufed medicines, and even food, he died on the eighth day of his illnefs. " By my attention to the fick man I caught the con- tagion, and began to be indifpofed on the 5th of Sep- tember, and the following is a narrative of my cafe, ex- tracted from notes daily marked down: I had been many years in Jamaica, but, except being fomewhat relaxed by the climate, and fatigue of bufinefs, I ailed nothing when I embarked. This circumftance, how- ever, might perhaps difpofe me more readily to receive the infection. " Sept. 5th, 6th, 7th, Small rigors now and then—a preternatural heat of the fkin—a dull pain„in the fore- head—the pulfe fmall and quick—a lofs of appetite, but no ficknefs at the ftomach—the tongue white and (limy—little or no thirft—the belly regular—the urine pale and rather fcanty—in the night reftlefs, with dart- ing and delirium. " Sept. 8th, Every fymptom aggravated, with pains in the loins and lower limbs, and ftiffnefs in the thighs and hams. " I took a gentle vomit on the fecond day of this illnefs, and next morning a decoction of tamarinds; at bed time, an opiate, joined with antimonial wine; but this did not procure deep, or open the pores of the fkin, No inflammatory fymptoms being prefent, a drachm of Peruvian bark was taken every hour for fix hours fuc- ceflively, and now and then a glafs of port wine, but with no apparent benefit. When upon deck, my pains were greatly mitigated, and the colder the air the better. This circumftance, and the failure of every means I had tried, encouraged me to put in practice on myfelf what I had often wiihed to try on others, in fevers fimilar to my own. J9 IC Sept. 9th, Having given the necefiary directions, about three o'clock in the afternoon I dripped off all my cloaths, and threw a fca-cloak loofely about me till I got upon the deck, when the cloak alfo was laid afide: three buckets full of fait water were then thrown at once upon me; the (hock was great, but I felt immediate relief. The head-ach and other pains inftantly abated, and a fine glow and diaphorefis fucceeded. Towards evening, however, the fame febrile fymptoms threatened a return, and I had again recourfe to the fame method as before, with the fame good effect. I now took food with an appetite, and for the firft time had a found night's reft. " Sept. 10th, No fever, but a little uneafinefs in the hams and thighs—ufed the cold bath twice. " Sept. 11 th, Every fymptom vanilhed, but to pre- vent a relapfe, I ufed the cold bath twice. " Mr. Thomas Kirk, a young gentleman, paifenger in the fame (hip, fell fick of a fever on the 9th of Aug. His fymptoms were nearly fimilar to mine, and having taken fome medicines without experiencing relief, he was defirous of trying the cold bath, which, with my approbation, he did on the nth and 12th of Sep- tember, and, by this method, was happily reftored to health. He lives at this time (Jan. 1786) near Liver- pool." To this interefting narrative, Dr. Wright adds fome general obfervations on the traces that are to be found of the ufe of cold water internally and externally in fevers, in feveral works ancient and modern. But whether he himfelf purfued this practice any farther, I have not been informed. Having before experienced that Dr. Wright was a 20 fafe cuidc * I immediately on reading this narrative, determined on following his praaice in the ,prefent: ,„- fiance s and before an opportunity occurred of carrying ^intention into effed, I was further encouraged, by learning, that my refpectable colleague, Dr Brandreth had employed cold water externally in fome recent cafes of fever with happy effects. * See a paper in the Memoirs of the London Medicnl Society, vol. p. 147, to be found in a subsequent part or this volume. 21 CHAP. II. Hiftory of a Fever which broke out in the Liverpool Infirmary. ON the 9th of Dec. 1787, a contagious fever made its appearance in the Liverpool Infirmary. For fome time previoufly the weather had been extremely cold, and the difcipline of the houfe, owing to caufes which it is unneceffary to mention, had been much relaxed. The intenfity of the cold prevented the neceffary degree of ventilation, and the regulations for the prefervation of cleanlinefs had been in fome meafure neglected. Thefe circumftances operated particularly on one of the wards of the eaftern wing, employed as a lock-hofpital for females, where the contagion firft ap- peared. The fever fpread rapidly, and before its pro- grefs could be arretted, fixteen perfons were affected, of which two died. Of thefe fixteen, eight were under my care. On this occafion I ufed for the firft time the af- fufion of cold water, in the manner defcribed by Dr. Wright. It was firft tried in two cafes only, the one on the fecond, the other on the fourth day of fever. The effects correfponded exactly with thofe mentioned by him to have occurred in his own cafe; and thus encouraged, I employed the remedy in five other cafes. It was re- peated daily, and of thefe feven patients, the whole recovered.—In the eighth cafe, the affufion of cold water feemed too hazardous a practice, and ir was not employ- 22 ed. The ilrength of this patient was much impaired by lues venerea, and at the time of catching the contagion, (he laboured under ptyalifm. I was not then aware that this laft circumftance formed no objection againft the cold affufion, and in a fituation fo critical, it was thought imprudent to ufe it. The ufual remedies were directed for this patient, particularly bark, wine, and opium, but unfuccefsfully; fhe died on the 16th day of her difeafe. From this time forth, I have conftantly wifhed to em- ploy the affufion of cold water in every cafe of the low contagious fever, in which the ftrength was not already much exhaufted; and I have preferved a regifter of a hundred and fifty-three cafes, in which the cure was chiefly trufted to this remedy. Of thefe, ninety-four occurred in the hofpital in the four years fubfequent to the period already mentioned, twenty-feven in private practice, and thirty-two in the 30th regiment of foot, when quar- tered in Liverpool in the year 1792. Of late (1797) I have not thought it neceffary to regifter all the cafes in which this remedy has been employed. Having fatisfied myfelf of its extraordinary efficacy, and of the precautions neceffary in ufing it, I have found it the fhorter method, as well as the more inftructive, to re- cord the inftances in which it has proved unfuccefsful. To detail the whole of my experience would be a tedious and an ufelefs labour. 1 purpofe to digeft the refults under a few diftinct heads, fupporting and il- luftrating each general propofition by an ample detail of cafes. Before, however, this preliminary account is clofed, it will be ufeful to enter more particularly into the hiftory of the contagious fever which broke out in the 30th regiment, becaufe the account of its rife, pro- grefs, treatment, and termination, will fupport in a ftriking manner, the doctrines I wifh to eftablifh, and if I do not greatly deceive myfelf, may afford important inftruction, as well as encouragement, to thofe whofe duty may call them to oppofe the progrefs of contagious ^ver in fimilar fituations. 2.3 CHAP. III. Hiftory of a Fever which occurred in the 30/^ Regiment. THE 30th regiment, as is ufual with troops in Liverpool, was billeted in the town, but paraded and mounted guard in the fort, fituated north of the town, on the banks of the river. The general guard- room had been ufed previous to the arrival of the 30th, as a place of confinement for deferters; it was extremely clofe and dirty, and under it was a cellar, which in the winter had been full of water. This water was now half evaporated, and from the furface iffued offenfive exhalations. In a dark, narrow, and unventilated cell, off the guard-room, it was ufual to confine fuch men as were fent to the guard for mifbehaviour, and about the 20th of May 1792, feveral men had been fhut up in this place on account of drunkennefs, and fuffered to remain there twenty-four hours, under the debility that fuc- ceeds intoxication. The typhus, or jail fever, made its appearance in two of thefe men about the firft of June, and fpread with great rapidity. Ten of the foldiers labouring under this epidemic, were received into the Liverpool Infirmary, and the wards allotted to fever could admit no more. The contagion continuing its progrefs, a temporary hofpital was fitted up at the fort, 24 and I was requefted to give my afliftance there to the fur^eon of the regiment, by Captains Brereton* and Torriano,f In two low rooms, each about fifteen feet fquare, were fourteen patients labouring under fever. They were in different ftages of its progrefs: one was in the, fourteenth day of the difeafe, two were in the twelfth, and the reft from the ninth to the fourth inclufive. The fymptoms of the fever were very uniform. In every cafe there was more or lefs cough, with mucous expectoration: in all thofe who had fuftained the difeafe ei^ht days and upwards, there were petechias on the (kin; in feveral there were occafional bleedings from the noftrils, and ftreaks df blood in the expectoration. The debility was confiderable from the firft, and it had been increafed in feveral cafes by the ufe of venefection, before the nature of the epidemic was underftood. The pulfe varied from 130 ftrokes in the minute to 100; the heat rofe in one cafe to 105 deg. of Fahrenheit, but was in general from 101 deg. to 103 deg.; and towards the latter ftages of the difeafe it was fcarcely above the tem- perature of health.—Great pain in the head, withftupor, pervaded the whole, and in feveral inftances there oc- curred a confiderable degree of the low delirium. Our firft care was to ventilate and clean the rooms, which were in a high degree foul and peftileotial. Our fecond was to wafti and clean the patients themfelves. This was done by pouring fea-water, in the manner already defcribed, over the naked bodies of thofe whofe ftren~:m of ebb is nearly pure. 41 was led to prefer fait water to frefh on account of the ftimulating effect of fea-fait on the veffels of the fkin, by which I apprehend the debilitating action of cold is prevented. Salt water, either for the purpofe of im- merfion or affufion, is more grateful to the patient than frefh water and it is well known that it may be applied to the furface for a length of time, with much lefs hazard. Perfons immerfed in fea water, and efpecially in faturated brine, for fome time together, preferve the luftre of the eye and the ruddinefs of the cheek, longer than thofe in frefh water, of an equal temperature, and fuch perfons exhibit the vital re-action ftronger when removed from it. I preferred the brine to vinegar, as being cheaper, and more eafily procured of the neceffary quantity : otherwife, it is well known how grateful vine- gar is to patients in fever, and perhaps a mixture of vi- negar and water of the proper ftrength, might be pre- ferable even to brine. But though I gave the preference to brine over frefh water, I have very often ufed the latter, and it is feldom that any danger can refult from the want of a faline impregnation, where the cold is employed in fo ftimulating a form as that which has been defcribed ; that is, fuddenly, and for fo temporary a duration. 3. In taking the heat of the patient, I have generally ufed a fmall mercurial thermometer of great fenfibility, with a moveable fcale, made for me by Mr. Ramfden, after a form invented by the late Mr. Hunter, and ufed by him in his experiments on the heat of animals, and I have introduced the bulb under the tongue with the lips clofe, or under the axilla, indifferently ; having found by repeated experiments, that the heat in thefe two places correfponds exactly, and gives a juft indication of the heat of the furface of the body, where fheltered by the neceffary teguments from the contact of the external air. Finding, however, confiderable rifque in ufing the ftraight tubed thermometer in contagious difeafes, I got fome inftruments of this kind made with a fmall bulb 6 42 and curved at the end. The bulb being introduced undrr the tongue or the axilla, the obferver can (land be- hind the patient, and mark the rife of the mercury, with- out coming into the immediate fphere of his refpiration. Though no injury was in any cafe incurred from the ufe of this thermometer, yet a farther improvement has fug- gefted itfelf. By introducing a fmall piece of iron into the tube, after the manner of Mr. Six, a permanent indi- cation of the greateft heat is obtained, and the approach of the obferver towards the patient during the experi- ment, is rendered unneceffary. 43 CHAP. VII. Precautions requiftte in ufing the Cold Affufion, itlus- trated by Cafes. i. TT was before remarked that the cold affufion can- X not be ufed with fafety during the cold ftage of the febrile paroxyfm: the following cafe will illuftrate this truth. In the fummer of 1792, I was requefted by Mr. Hoffman, an ingenious Pruffian gentleman, and a furgeon in the army then under the command of the Duke of Brunfwick, to give him an opportunity of feeing the method of ufing this remedy. At that time there was a patient labouring under a tertian intermittent under my care in the infirmary, on whom it could with propriety be exhibited. Accordingly a time for meet- ing Mr. Hoffman in the fever-ward was appointed, when the hot ftage of the paroxyfm might be expected to be fairly formed. It happened however that the ac- ceffion of the fever had occurred an hour later this day than might have been expected, and when we arrived, the patient was ftill in the cold ftage of the paroxyfm; the affiftants however proceeded: he was taken out of his bed fhivering, his pulfe fmall and frequent, his ex- tremities fhrunk and cold. In this ftate the brine was dafhed over him as ufual, but not with the ufual happy effects;—his breathing was for fome minutes almoft fuf- pended; his pulfe at the wrift was not to be felt; the pulfations of the heart were feeble and fluttering; a 44 deadly coldncfs fpread over the furface; arid when refpi- ration returned, it was fhort, irregular, and laborious. After the ufe of frictions on the furface, and particular- ly on the extremities—of a fteady warmth applied for fome time to the fcrobiculus cordis—and of cordials cautioufly adminiftered in fmall quantities—the pulfe at the wrift returned; but for fome time it was exceffive- ly quick and feeble. He recovered however in the courfe of an hour, and it was found that the paroxyfm of fever had been extinguifhed : but the circumftances firft related, were evidently full of danger, and they produced at the time much apprehenfion and uneafinefs. The fame remedy was however ufed in the hot ftage of the enfuing paroxyfm, and with the ufual happy effects. Other cafes to the fame purpofe might be adduced if it were neceffary. I have frequently ufed the cold affufion in the hot ftage of the paroxyfm of intermittents, and almoft al- ways with the immediate folution of the fit; but in ge- neral, if no remedy be ufed in the intermiffion, the fe- ver returns at the ufual period. In fome inftances, however, the fucceeding paroxyfm has been prevented by ufing the cold affufion about an hour previous to the period of its expected return, and the difeafe ultimately removed by continuing this practice through four or five of the following periods. The ufe of the cold affufion in the abfence of fever, requires however a conftitution in a great meafure un- broken; and many of the intermittents which we fee in Liverpool, being tranfmitted to us from the warm cli- mates, adhere to conftitutions in which this practice is not perfectly fafe. In fuch cafes, it may notwithftand- ing be adopted in the hot ftage of fever with fafety and advantage. Indeed it ought never to be forgotten, that an application of cold, which is fafe in the violence of fever, is not fafe when the fever is removed. Injury 45 has fometimes occurred from continuing the cold affu- fion in the period of convalefcence. 2. Neither is the cold affufion fafe after the fweating ftage of fever has continued fome time, and the body is paffing through that cooling procefs. The following cafe will illuftrate this pofuion. In the fummer of 1791, a boy of eight years of age, in whom I am peculiarly interefted, was attacked by fever. On the third day his pulfe rofe to 130, and 140 in the minute, and his heat to 106 deg. and 107 deg. of Fahrenheit. Hi9 thirft was very great, and delirium commenced on the fecond day, and continued without intermiffion. Va- rious methods had been employed to abate the fever, and particularly to excite fenfible perfpiration, but un- fu'ccefsfully. His heat was not leffened by repeated fpunging of the furface of the body with cold vinegar and water: and after a copious bleeding, all the fymp- toms were as alarming as before. It feemed hazardous to repeat this evacuation, as the blood exhibited no fize, and there was a fufpicion that the difeafe originated in contagion. The patient had taken antimonials with- out any apparent effect, and after watching the ftate of the thermometer, with the bulb at the axilla, upwards of an hour, though the mercury had funk a fingle de- gree in that interval, it flood at the end of the time as high as 106 deg. In this ftate of things we refolved on trying the cold affufion, and every thing being prepared, he was ftripped naked and lifted out of bed. As we were about to throw the water upon him, it was obfer- ved that a fenfible perfpiration had broken out all over him, but the heat being fo great, we perfifted in our purpofe, and four gallons of frefh water of the tempe- rature of 60 deg. were dafhed upon him; the effects were altogether furprifing. On replacing him in bed, the mercury in the thermometer (the bulb at the axilla as before) rofe to 98 deg. only, and the burning heat of the extremities was converted into a coolnefs that was rather alarming; the pulfe had funk in frequency 4& to 90 deg. but was full and fteady. Gentle frictions were applied to the legs and feet, but they were not long continued, for the general warmth fpeedily return*- ed; the heat in the trunk of the body rofe in about an hour to 100 deg. and the pulfe to 100. His delirium went entirely off; the fur on his tongue fpeedily difap- peared; and twenty hours afterwards he was found free of every complaint but debility. Subfequent experience has however convinced me, that though in this cafe the termination was fo happy, the cold affufion was not unattended with hazard. Sweat- ing had commenced, and the heat was finking. It had perhaps funk more at the moment when the affufion was performed, than was indicated by the thermometer, for the bed clothes often keep the body from cooling under fweating, to the degree that would otherwife be produced. In this cafe when the furface is fuddenly expofed to the external air, the heat finks rapidly. If the fweat had continued an hour longer before this re- medy was ufed, the heat would have been ftill more di- miniihed ; a torpor of the veffels of the furface, and of the extremities, would have been produced, followed by a great, and probably a dangerous re-action of the centre. This observation will be illuftrated in the fe- quel. In recommending the affufion of cold water as a re- medy in fever, an exprefs exception is therefore made againft its life during the feverifh chill, or after the fweat has begun to flow profufely, and more efpecially after it has continued to flow profufely for fome time. An exception is alfo made againft its being employed in the latter end of fever when theftrength is much exhaufted, and the heat is fometimes as low or lower than the tem- perature of health. While, however, the heat rifes one or two degrees above the healthy ftandard, this remedy may be ufed even in the latter iiages of ftver. I have employed it with advantage on the nth, 12th, and 47 13th days. In inftances of this kind it will however be prudent to make the degree of cold very moderate, as has been already obferved; and as it is fcarcely to be expected, that at an advanced period of the difeafe the progrefs of it can be flopped, or its duration much lef- fened, it may perhaps anfwer every purpofe to employ in fuch cafes the tepid affufion. I have indeed often contented myfelf with fpunging the body all over with tepid vinegar, or vinegar and water, from the 9th or 10th day forwards -, but I have frequently in cafes where the heat continued high, directed the general affufion of tepid water, by which the heat may always be fpee- dily and effectually reduced, when that is the only object in view. Under thefe reftrictions, the affufion of cold water may be ufed with perfect fafety in the low contagious fever of this country, and the facts already flated, will fhow that it is a remedy of great power and efficacy. In the firft ftages of fever, it appears very generally to cut fhort the difeafe almoft inftantaneoufly; and even when it fails of this effect, as is ufually the cafe when it is applied in the more advanced ftages, it neverthelefs moderates the violence of the fymptoms, and fhortens the duration of the difeafe. 48 CHAP. VIII. General Remarks on Fever. Hiftory of a Cafe of Fever in which the Affufion of Cold Water was not falutary. SINCE the introduction of fcientific arrangements into medicine, difeafes have been much reduced in number, and their nature has been more clearly under- ftood. This is efpecially true of continued fever, which is exhibited by Dr. Cullen under three genera only, Sy- nocha, Typhus, and Synochus. Of thefe genera, how- ever, the Synocha, or pure inflammatory fever, without topical inflammation, is confeffedly a very rare occur- rence in this ifland; the venerable profeffor ufed to de- clare that he had not met with a fingle inftance of it in forty years practice.—And the Typhus and Synocus seem to be confidered by him as the fame difeafe, modi- fied differently, by the difference of climate, feafon, and constitution. Both are defcribed as contagious, and as occafionally producing each other. • Doubtlefs the Ty- phus, or low contagious fever, is the prevailing fever of this ifland, and of Europe. It is the epidemic of all our great towns, of our jails, hofpitals, and manufactories; its origin and progrefs are clearly afcertained, and its fymptoms generally underftood. It is to this fever that the preceding obfervations chiefly apply. I have my doubts, however, after much reflection and obfervation, whether we have not Amplified too far in our nofological arrangements of fever. The dreadful 49 difeafe which prevailed lately at Philadelphia, and which now ravages the Weft Indies, (1798), cannot perhaps be included without fome violence within our fyftems of Nofology ; and its fatality under all the eftablifhed modes of treatment, whilft it excites our deepeft regret, muft ferve to abate the pride of modern fcience. Even in our own ifland, it appears to me that cafes of fever fometimes occur, which cannot be referred with advan- tage to any of the genera of Dr. Cullen*. The follow- ing is a defcription of a fever of this kind; I have not met with it often, but when I have met with it, it has very generally proved fatal, under the eftablifhed modes of treatment; and I am forry to fay, that in the only inftance of this fever in which I have tried it, the effufion of cold water proved unfuccefsful.alfo. The fever in queftion does not feem to originate in contagion, or to propagate itfelf by contagion. I have never been able in a fingle inftance to trace it to that fource, nor have I ever found it to be communicated from the patient to any of his attendants. The cafes which I have feen have occurred chiefly in the winter feafon, in perfons in the flower or vigour of life, poffefs- ed of confiderable fenfibility of mind, and in the habits of more than ordinary mental exertion. After fome days of indiftinct catarrhal complaints, the fever comes on, (in general after fome accidental expofure to cold), with a very violent and long continued attack of chills and rigor, and to this, as is ufual, fucceeds a ftate of heat and re-action. The patient complains of intenfe head-ache and of oppreffion at the prascordia, with occa- fional but not fevere cough, and with fome increafe in the frequency of refpiration. His pulfe is not remarka- ble as to frequency or ftrength ; his fleep is not particu- * I am aware that all queftions respecting nofological arrangement have a tendency to degenerate into verbal difputes, and I willingly avoid them, referring for my accuracy to thofe who have ftudied difeafes, not in books only, but in the volume of nature. 7 5° larly difturbed ; and for fome days the complaint goes on as if produced by catarrhal fever. From the firft, however, there appears a great quicknefs and impatience about the patient: he talks more rapidly than ufual; apprehends you quickly, and anfwers you inftantly. He cannot, however, command his attention long, and is fatigued with the effort. His heat, which was at firft moderate, becomes very great on the 7th and 8th day, reaching 107 and 108 deg. of Fahrenheit; he becomes delirious and talks inceffantly. Throughout the fever, his fenfes of hearing and tafte are uniformly acute, and this is true alfo of his fense of feeling. Great as his heat is, he is much alive to the impreffions of cold on the furface of the body and fhrinks from them. At times he appears furprifingly calm and natural, gets out of bed and dreffes himfelf, infilling that he is well. Often he ftarts up fuddenly in bed and opens his curtains, feeming to look round the room for fome perfon he fuppofes prefent; and fometimes he rings the bell vio- lently, if within his reach, without apparent object. In- diftinct conceptions rife and vanifh in his mind, and the impreffions of fenfe are confounded with the ideas of imagination. As the fever advances, the refpiration be- co nes more hurried and laborious, the pulfe more fre- quent and feeble; and towards the latter end of the dif- eafe, but not before, fweats break out, at firft partial, and at length general and profufe, which however, though they reduce the heat, do not otherwife relieve him. The pulfe finks; the body is covered with pete- chia; ; wine, bark, opium, and blifters afford no relief: the patient dies on the twelfth or thirteenth day of fever, and after death the body runs rapidly into putrefaction. I have feen this fever treated by venefection and an- timonials in the early ftages, with a ftrict attention to the antiphlogiftic regimen; and by bark and cordials, as the ftrength began to decline; but without fuccefs. 1 have alio feen it treated from the firft on the fame plan as ty- phus, but with an equally unfortunate ifiue, In a cafe 5* of this fever which occurred lately, I made ufe of the cold affufion, and as the mercury rofe in the thermome- ter with the bulb under the tongue, to 107 deg. I em- ployed this remedy with fome degree of confidence. The effects did not correfpond with my former experi- ence or with my hopes. The patient felt the cold mod acutely, but was not relieved. His pulfe did not di- minifh in frequency; his heat fubfided very little, and that for a few minutes only; neither diaphorefis nor fleep followed. This remedy was not repeated, but the fur- face of the body was fpunged from time to time with vinegar, without however producing fenfible benefit or refrefhment. I have already mentioned that the affufion of cold water is not to be ufed after a profufe perfpiration has taken place; and that it is not to be ufed in the cold ftage which begins the paroxyfm of fever, nor till the hot ftage be fairly formed. In the typhus, however, this laft reftriction feldom requires us to wait long; the affufion may be ufed in general in twenty-four hours from the original attack, and often much fooner. The cafe I have juft related is the only inftance, out of many hundred trials, in which I found, that even on the fixth day of fever, with the actual heat of the body far above the temperature of health, the affufion of cold water was neither falutary nor refrefhing. I have however to ob- ferve, that notwithstanding the great heat of the body, producing the utmoft reftleifnefs and anxiety, the fenfa- tion of heat was interrupted by chillinefs on the flighteft application of cold, and that the furface and extremities not only felt chilly, but grew cold, even on the acceffion of the external air. In reality, through the greater part of the fever, the ftate of the patient had a confiderable refemblance to what we fee in the paroxyfm of an inter- mittent, when the cold ftar e is terminating, but the hot ftage not fairly formed—when the heat, as well as the blood, is accumulated in the centre of the fyftem and the-vital power is ftruggling to give them that propul- 5-2 fion-to the fuperficies, which terminates in profufe per- fpiration, and carries off the difeafe. I have little doubt that immerfion in the tepid bath of the temperature that feels comfortably warm to the fkin, continued for fome time, is the proper remedy in the fever I have defcribed, as it doubtlefs is in the ftruggle of the paroxyfm of in- termittent ; and when an opportunity offers, I mean to afcertain the truth on this point. But this opinion will be illuftrated when we come to ipeak of the warm bath more particularly. If any one fhould contend that the fever I have de- fcribed is in reality only a variety of the typhus, or fy- nochus, I fhall not be difpofed to conteft the matter. The queftion concerning identity, leads to endlefs dif- putes in every branch of fcience where it occurs, and he muft know little of nofology, who fuppofes // has yet received a confiftency, that would render fuch a difcuf- fion profitable. It is fufficient for me to obferve, that the fymptoms of the two difeafes are in a confiderable de- gree different, though with that general fimilarity that belongs to all cafes of fever; that the ftate of the ner- vous fyftem as to impreflibility is widely different; and what is of mod importance, that the methods of treat- ment, which according to my experience almoft invaria- bly fucceed in the one difeafe, are unfuccefsful in the other. Every practitioner knows, that in typhus, the fenfe of hearing is generally obtufe; and the fame may be laid of the tafte, fmell, and touch ; whether the ob- fervation is applicable to the fight alfo, and under what reftriction, appears to me doubtful. The acutenefs of all thefe fenfes in the fever which I have defcribed, is very remarkable, and particularly in regard to the fenfi- bility of the furface. I have obferved this fymptom to be produced by feveral narcotics, and by fome poifons. It is very remarkable in the hydrophobia; and in the laft days of a perfon who died of inanition, the fenfes of touch and vifion were extremely acute.* • This cafe will be found in chap. xix. 53 CHAP. IX. Of the Ufe of the Affufion of Cold and Tepid Water in Small-pox, with Cafes. THE fingular degree of fuccefs, that on the whole attended the affufion of cold water in typhus, en- couraged a trial of this remedy in fome other febrile dif- eafes. Of thefe the fmall-pox feemed more particularly to invite its ufe. The great advantage that is experi- enced in this difeafe by the admiffion of cool air, feemed to point out the external ufe of cold water, which being a more powerful application, might be more particularly adapted to the more malignant forms of fmall-pox. The refult correfponded entirely with my expectation. Of a number of cafes in which I witneffed the happy effects of the affufion of cold water in fmall-pox, I fhall give the following only. CASE I. In the autumn of 1794, J. J. an American gentleman in the 24th year of his age, and immediately on his landing in Liverpool, was inoculated under my care; the prevalence of the fmall-pox rendering it imprudent to wait till the ufual preparations could be gone through, or indeed till he fhould recover from the fatigues of the 54 voyage. He fickened on the feventh day, and the erup- tive fever was very confiderable. He had a rapid and feeble pulfe, a foetid breath, with pain in the head, back, and loins. His heat rofe in a few hours to 107 deg. and his pulfe beat 119 times in the minute. I en- couraged him to drink largely of cold water and lemon- ade, and threw three gallons of cold brine over him. He was in a high degree refrefhed by it. The eruptive fever abated in every refpect—an incipient delirium fubfided, the pulfe became flower, the heat was re- duced, and tranquil fleep followed. In the courfe of twenty four hours the affufion was repeated three or four different times at his own defire; a general direction having been given him to call for it as often as the fymp- toms of fever returned. The eruption, though more numerous than is ufual from inoculation, was of a fa- vourable kind. There was little or no fecondary fever, and he recovered rapidly. In fituations where the eruptive fever of fmall-pox is clearly diftinguifhable, and where it does not abate fuf- ficiently on the admiffion of cold air, the affufion of cold water may be reforted to with confidence and fafety, re- gulated however in this application, as in every other, by the actual ftate ofthepatient's heat, and of his fenfa- tion of heat. In the confluent fmall-pox, however, af- ter the eruption is completely formed, this remedy can- not perhaps be ufed with advantage. The following cafe will illuftrate this pofition. H. A. aged 23, an American mariner, fell under my care (Dec. 7,) on the third day of the eruption of the fmall-pox; that is, on the fixth day of the difeafe. His pulfe 114 and feeble, his heat 109 deg. His head, back, and loins, ached feverely—thirft great—fkin livid— fmall-pox confluent. He was put on a milk diet—gentle mercurial purga- tives were ordered from time to time, and an opiate every 55 night at bed-time. Lemonade was given largely at firft by itfelf, and afterwards mixed with wine, and the affu- fion of cold water was directed in the ufual way. In ten minutes after the affufion, the pulfe was 96, the heat 98 deg.; the livor of the fkin was much diminifhed, but the pains were not relieved. Dec. 8. Noon—Pulfe 96, foft and regular—thirft gone—refpiration flow and natural—heat 97 deg. The affufion was ordered to be repeated; ten minutes after, pulfe 84 and feeble—heat 84 deg. Dec. 9. Noon—Pulfe 88, heat 93 deg.—the cold af- fufion was not repeated in this very reduced ftate of heat; the decoction of bark was ordered, and a pint of wine daily in lemonade. Dec. 10. Noon—Pulfe 116, and full—heat 98 deg. refpiration ftill eafy—expectoration confiderable, and vifcid—thirft lefs—eyes quite clofed—head fwelled__a complete union of the puftules on the face.—Bark and wine continued, with the opiate at night. Dec. 12. Pulfe 118—heat 96 deg. A bucket full of water of the temperature of 92 deg. was poured over him. He appeared refrefhed at the moment; ten minutes after, pulfe 112, heat 94 deg. Complained of being chilly. Refpiration ftill eafy—free of pains, and his face lefs fwelred. Complained of his throat. A blifter was applied to it all round. Dec. 13. Noon—Pulfe 118—heat 96 deg.—refpira- tion ftill free, but his throat very fore. Medicines were continued, but the affufion of tepid water was not re- peated. Dec. 14. Noon—Pulfe 138—heat 100 deg.—ref- piration had now become laborious, and the expuition difficult. The throat was much fwelled. He was fre- 56 quently fponged with tepid water, and the medicines continued. Dec. 15. Noon—Unfavourable fymptoms increafed. Dec. 16. Noon—Vomiting came on, which was re- lieved by opium. His fenfes and his intellect remained acute till within an hour of his death, which happened at eight o'clock in the evening of this day. • If this cafe be more detailed than feems neceffary, let this beexcufed, as it is the firft in which the actual heat in confluent fmall-pox has been recorded. It is here given accurately from the period when the difeafe came under my care. In regard to the effects of the cold affufion, it may be obferved, that this remedy was not ufed during the eruptive fever, nor till three days after the eruption had appeared, and the character of the difeafe was decided. In the ftage in which it was employed, the fever and the heat were abating, as is ufual after the eruption; and in all cafes in which the heat is finking, the application of cold muft be made with great caution, as has already been mentioned. After the fecond affufion (on the 8th) the heat funk below its natural ftandard, and continued below it for fome time; fo that this remedy.became in- admiffible. The difeafe went through its ufual courfe. The tepid affufion on the eighth day of the eruption (Dec. 11) was ufed in part to wafh off variolous mat- ter, and in part to produce refrefhment. The heat which was before 96 deg. funk two degrees, fo that it could not with fafety be continued, for experience has proved, that the tepid affufion is a powerful means of diminifhing heat. The heat rofe again with the fecon- dary fever, and the patient died of the affection of the throat, as I believe is general in the confluent fmall- 57 pox.* It will be at once perceived± on the principles already laid down, that in a difeafe like this* the affufion of cold water could only be effentially ufeful during the erup- tive fever. It is during the eruptive fever that the quan- tity of the affimilation is determined, as well as its kind. This is, I believe, invariably found to bear an exact proportion to the eruptive fever, and whether we eonfi- der the eruptive fever as the cause or effect of the affi- milation, there is every reafort to expect from the laws of the living fyftem, that the diminution of this fever will diminifh the quantity, and meliorate the quality of the variolous eruption. I In the cafe juft related, the heat during the eruptive fever (judging from trials in fimilar fituations) had rifen to 106 deg. or 107 deg;-f but it had funk to 100 deg. before the cold affufion was employed. It may eafily be conceived that this remedy could have been employ- ed to a much greater extent, and that its effects would have been far more falutary, if it had been ufed throughout the previous fever. That it would have ef- fentially altered the character of the difeafe, I prefume not to affert. This however, I can declare, that in all the cafes in which I have ufed the affufion of cold water during the eruptive fever, however fevere the fymptoms may have been, thefe fymptoms inftantly abated, and the difeafe affumed a benignant form. The cafe of Mr. Johnfton (Cafe I.) already given, will illuftrate this ob- servation ; and fix or feven others I might adduce to the fame purpofe. As yet my experience extends no further. The inoculation of infants is fo very rarely followed by any ferious difeafe, that as far as refpects them, the affufion of cold water may be feldom required. The inoculation of adults is not, however, quite fo fafe. * See Zoonomia, vol. ii. page 237. f 1803. I now believe that the heat does not rife fo high in any ftage of eorjfluent $mall-pox. See the Additional Report^. 8 5« Inoculation is feldom indeed performed in our ifland on adults that are natives, but foreigners frequently require it; and in Liverpool, our intercourfe with America renders it often neceffary to perform it on adults from that continent. We may alfo obferve, that when the na- tural fmall-pox is epidemic, the eruptive fever will be generally diftinguifhable, and wherever it is diftinguifh- ed with fymptoms of violence, inftead of. trufting to cool air only, the cold affufion, or cold bath, is ftrongly recommended. To our brethren acrofs the Atlantic this is more efpecially addreffed.—In America, as well as many parts of the old continent, in confequence of the neglect of early inoculation, the natural fmall-pox at times fpreads alarm and devaftation throughout ex- tenfive diftricts. In this ifland the ravages of the natu- ral fmall-pox are on the whole very great, yet they occa- fion little difturbance or alarm. The practice of inocu- lation among the more opulent claffes of fociety, keeps up the contagion in all our populous diftricts, and at the fame time by relieving thefe claffes from the apprehen- fion of the natural fmall-pox in their own families, pre- vents them from oppofing the cafual progrefs of the dif- eafe among the inferior orders, who want the knowledge and the combination neceffary to the ufe of the means of prevention among themfelves. Though therefore it is demonftrable, and has indeed been demonftrated, that the deftruction of the natural, or rather the cafual fmall- pox, might be entirely avoided, yet, as it falls almoft wholly on the families of the poor, and as it has been an evil that has been long, and that is familiarly known, we submit to it through habit, as if it were inevitable.* * The obfervations on the poflible prevention of the cafual fmall-pox, will doubtlei's fuggelt to the medical reader, the •' Sketch of a Plan" fot that purpofe, publifhed in 1793, by my refpc6lable neighbour, Dr. Hay- gaith. That this plan is in tifelf practicable, and that it would be ef- l\£tual, I have little doubt. Unfoi tunately, it requires the afliftance of government (as I remarked at the time) and thia I fear is a powerful ob- jection. It is poflible however that fome icheme of ihis kind (including I hope all contagious difeafes) may one day or another be attached to fome rorvprelierifive plan for the management of the poor. 59 The alarm produced by the cafual contagion is therefore feldom fo great in our large towns, as to give a practi- tioner frequent opportunities of treating the eruptive fe- ver of the confluent fmall-pox, the only ftage of that difeafe in which medical treatment is likely to be of much avail. Where fuch an opportunity does occur to the judicious reader of thefe pages, it is hoped that the The theory that fuggestted Dr. Haygarth's plan, but which formed no effential part of it, involved him in a difcuflion on the length of time that variolous matter may be expofed to the atmofphere, and retain its infec- tious quality. On this occafion, as there was fome difference of opinion between us, he propofed feveral experiments to me, which would doubt- lefs have decided the queftion. (See p. 459, 460, of" A Sketch, Sec.'"') It was fully my intention to have undertaken fome experiments fuch as he mentioned, and I even commenced them, but as my attention was forcibly drawn to other fubjecls, thefe experiments, which required ex- treme accuracy, were not completed, and my engagements have never fince permitted me to recommence them. I have, however, fince that time, inoculated with matter at •different periods from its being taken from the patient, and the refultis as follows:—The length of time which vario- lous matter expofed to the air retains its contagious quality, depends on its iuperficies. If it be fpread very thin on a piece of flat ox convex glafs, it loles this quality much fooner than when it is collected in a rnafs. Spread thin upon glafs, it fometimes difappoints the inoculatorat the end of twenty days, though not generally ; and I ha*ve known it Aicceed in com- municating the difeafe, even when diffufed over a large furface, at .the { Fe- bruary, 179?., I took a confiderable quantify of this matter on a piece of window glafs, keeping it as much together as its fluidity would admit. It was expofed immediately to a ftieam of air, and the furface was fpeedily dry. On the fecond of March following, after moiftening a portion of it with a little water, I inoculated three patients, and all with fuccefs. In the courfe of the fummer I inoculated with another portion of it, pre- vioufly liquified by the addition of warm water, and with fuccefs as be- fore. On the twentieth of July, 1793, I again ufed a portion of the fame matter in the fame way, and again with fuccefs4 but this fuccefs was long doubtful, and it was not till the twenty-fecond day after the opera- tion, that the patient fickened.—I ufed the fame matter in June, 1794, when it entirely failed me. It is now by me, and is not mouldy, nor any ways changed in its appearance. Variolous matter kept fome time is certainly flower in producing fhe difeafe, even where it does fucceed in the end. 1803. The happy difcovery of the certain method of preventing, and of finally annihilating the fmall-pox, given to the world by Dr. Jenner, deprives experiments of this kind of much of their utility and interefr. 6q affufion of cold water, or the cold bath, will not be neglected. The Chinefe, it is faid, have long followed this practice with extraordinary fuccefs*. The ufe of the cold affufion in fever was common among the phyficians of the infirmary, (Dr. Brandreth, Dr. Gera'd, and myfelf), while fevers were received into that hofpital, and its extraordinary fuccefs there, has rendered it in Liverpool familiar in private practice, and extended it, as I have already mentioned, to feveral other febrile diforders. The scarlatina anginofa, has for many years prevailed in Liverpool, and though in general mild, has, as at particular feafons been malignant and fatal. To this difeafe, the affufion of cold water has lately been applied by my friend Dr. Gerard, and the particulars that follow are mentioned on his authority. • In the latter end of December 1796, all the children of a family in his neighbourhood, five in number, had been attacked in fucceffion with fcarlet fever; four of thefe were recovering, but one was dangeroufly ill, when the father of the family, with whom one of the children had flept, was himfelf feized with all the fymp- toms of the difeafe. He had exceffive pain in his head and back, and flying pains all over him. He had fre- quent rigors, lofs of appetite, and ficknefs, with fome * Sir William Watfon, in his traft, entitled " Account of Experiments en the moft fuccefsful methods of inoculating the fmall pox," publifhed in 1761, mentions the cafe of a young woman, who in the abfence of her nurfe, got out of bed delirious during the eruptive fever of fmall-pox, and threw herfelf into the new iiver near Iflington She was difcovtred floating on her face; and when taken out of the water, had not the leaft appearance of life. She was recovered however by the ufual methods, and afterwards paffed well through the difeafe. In fome parts of Bengal, according to Mr. Ives, inoculation is prac« tifed among the natives.—After the opeiation is performed, the pat ent is ordered to bathe in cold water thrice a day, and to live on the moft cool- ing diet. When the fever comes on, the bathing is left off, but it is re- fumed on the fecond day after the eruption appears, and continued for the three fucceffive days. It is fuppofed to fill the puftules. Ives's Voyage to India, in the years 1755, 6, 7, cb. iv. p. 54. 6i flufhing of the face, but without any efflorefcence on the fkin, or affection of the throat. This was his fitua- tion when Dr, Gerard was called in, about fixteen hours after the firft attack. An emetic, and afterwards a ca- thartic were ordered, but their operation was flow and imperfect, and on vifiting him, ten or twelve hours af- terwards, he was not materially relieved. Entertaining no fort of doubt of the nature of the attack, and thefe fymptoms foreboding that the epide- mic would, in this inftance be fevere, Dr. Gerard de- termined to try the affufion of cold water, from which in typhus he had feen fuch happy effects. According- ly the operation was performed, and with a refult that far exceeded his hopes. As the patient was much de- bilitated, half a pint of hot wine was given him after it, and on being put to bed, the fymptoms of fever were found nearly gone; a genial warmth diffufed itfelf over the extremities of his body, followed by fenfible perfpi- ration and fleep. Next day he complained of a flight degree of head-ache and laffitude; Dr. Gerard therefore ordered the affufion to be repeated, as well as the warm wine after it; the fymptoms of the difeafe vanifhed, and never re-appeared. A day or two afterwards, a maid who had been hired as an affiftant to attend the fick children, and who had been about a week in the houfe, was attacked by the precife fymptoms already related, and which had uni- formly ufhered in the epidemic. She took an emetic on the firft attack with little benefit, and foon after the cold water was poured over her, the wine being admi- niftered after it. In this cafe the remedies were ufed earlier than in the former one;—they were ufed once only: the febrile paroxyfm was diffolved, and never re- turned. The refult of thefe cafes communicated by Dr. Ge- rard, leads to a variety of important reflections. That 62 the affufion of cold water extinguifhes the incipient fcarlatina as well as the typhus, can fcarcely be doubt- ed ; and thus this powerful and fimple remedy is ex- tended to another, and a moft important clafs of difeafes. That the difeafe may be extinguifhed without the fpeci- fic effiorefcence of the fkin, or affection of the throat, is a circumftance not a little curious. It feems to de- monftrate that this effiorefcent matter is the product of the eruptive fever; and that the fever itfelf being de- ftroyed in the firft inftance, the effiorefcent matter is ne- ver produced. Thus we are freed from the apprehen- fions which a falfe theory might fuggeft againft extin- guishing a procefs by which nature was extricating it- felf from an acrimony which the fyftem had imbibed. Thus alfo our conclufion is fupported, that the eruptive fever of fmall-pox is the caufe, and not, as fome have fuppofed, the confequence of the progrefs of affimila- tion, and that the diminution of this fever by cool air, and ftill more by the affufion of cold water, actually di- minifhes the quantity of matter affimilated, and in cer- tain cafes might perhaps wholly prevent the affimila- tion.* This laft conclufion is indeed doubtful, as all analogical inductions muft be between different difeafes j and particularly where the difference is of this import- ant kind, that the conftitution in one cafe is fufceptible of the difeafe once only, while in the other it may pro- bably receive it indefinicely.f We may alfo obferve, that the prevention of the affimilation of fmall-pox, bv wholly extinguifhing the eruptive fever, if it were in our * Dr. Cullen has affumed, that in all the various degrees of fmall-pox, the quantity of matter affimilated bears an exact proportion to the bulk of the body, and that the difference in the nature and quantity of the eruption depends wholly on the permeabdity of the fkin. This doclrine, which in his lectures he extended to all other exanthemata, is in my judgment, one of the weakeft parts of his moft valuable woik. f (1803) I was of opinion that the fame perfon might be again and 3aain affected by fcarlatina, but experience leads me to a different conclu- fion. I now believe that fcarlatina, like fmall-pox and meazles, affefts the i'.ime perfon once only. In the Additional Reports, the reader will fee an ample detail of my further experience of the nature and treatmejit of this difeafe. 63 power, would not be advifable, fince it muft leave the patient expofed to the future influence of that conta- gion. I have not had an opportunity of repeating Dr. Ge- rard's practice in the incipient ftage of fcarlatina, but after the efflorefcence on the furface decides the nature of the attack, I have for the laft fifteen months uniform- ly prefcribed immerfion in the tepid bath, (from 92 deg. to 96 deg.), and with ftriking benefit. Whether the af- fufion of cold water is applicable to the other exanthe- mata, muft be left to future experience. In the cafes that I have related to illuftrate the effects of the cold affufion, the temperature of the water may be judged of from the feafon of the year. In general it was from 40 deg. to 50 deg. of Fahrenheit. In the epidemic which prevailed in the 30th regiment, the wa- ter of the river was employed, as has already been men- tioned, which as the feafon was uncommonly cold, did not, though in the month of June, exceed 58 deg. or 60 degrees. I have, however, very often ufed the river water in private practice during the fummer months of the laft four years, when in general it has been from 65 deg. to 70 degrees, and the effects correfponded with thofe already defcribed. The folution of fever depends chiefly on the fudden, general, and powerful impreffion on the fenfations, and this impreffion is lefs affected by the difference in the temperature from 4odeg. to 65 deer. as far as my obfervation extends, than might on a firft confederation be imagined. Within thefe limits the ef- ficacy of this remedy, as well perhaps as its fafety, de- pends on the fuddennefs and momentarinefs of its appli- cation. The powerful impreffion on the fenfations is much weakened when the water is poured flowly on the body, and as the refpiration is fufpended or convulfed during this application, as well as during the act of im- merfion in the cold bath, it might in fome cafes incur hazard to protract it. 64. CHAP. X, Of the Affufion of Tepid Water on the Surface of the Body, in Feverifh Diforders, and of Sponging the Body with Water or Vinegar. The Affufion of Te- pid Water pratlifed by the Ancients. I APPLY the term tepid to water heated to that de- gree which is warm but not hot to the fenfations,, and which in the way of affufion is from 87 deg. to 97 deg. of the fcale of Fahrenheit. According to my ex- perience, this term, when the body is immerfed, may be applied to water fome degrees colder j the reafon of which will be eafily underftood by thofe who reflect, that under immerfion no evaporation from the furface of the body takes place. At firft I imagined that the tepid affufion might be beneficial in cafes where the heat of the body is below the degree neceffary to render the cold affufion fafe. I employed it therefore in thofe fta- ges of fever where the heat did not exceed the tempera- ture of health. A little experience however convinced me that this practice required ftricl attention, for I found, that in many cafes, atleaft, the heat of the living body is lowered as fpeedily by the affufion of tepid wa- ter, as by the affufion of water that is cold:—if I mif- take not, in fome cafes the heat is lowered more fpeedi- ly by the tepid water. To thofe who reafon refpecting the heating and cooling of the living body in the fame manner as refpecting inanimate matter, this obfervation 65 will appear paradoxical; I affert it however from actual obfervation, and a little reflection will explain the phe- nomenon. The evaporation from the furface is more copious from the tepid affufion, and on this the cooling of the body very much depends. But this is not all; the tepid affufion is little if at all ftimulating, and does not, like the cold affufion, roufe the fyftem to thofe ac- tions by which heat is evolved, and the effects of exter- nal cold are refilled. Where the object is to diminifh heat, that may be obtained with great certainty by the repeated ufe of the tepid affufion, fuffering the furface of the body to be expofed in the interval to the external air—and if the beams of the fun are excluded, and a ftream of wind blows over it, the heat may thus be re- duced where cold water cannot be procured ; even in the warmeft regions of the earth—on the plains of Bengal, or the fands of Arabia. I have accordingly employed the tepid affufion very generally in thofe feverifh affec- tions where the morbid actions are weakly affociated, depending rather on the ftimulus of preternatural heat, than on contagion, miafmata, the morbid contents of the ftomach and bowels, or local inflammatory affections of this kind are a great part of the feverifh affections of children, in which the tepid affufion is a valuable reme- dy. It very generally produces a confiderable diminu- tion of heat, a diminifhed frequency of the pulfe and refpiration, and a tendency to repofe and fleep. I have ufed it alfo in feverifh diforders of various kinds where the lungs are oppreffed, and the refpiration labo- rious, and where of courfe the oppreffion might be dan- geroufly augmented by the fudden ftimulus of the cold affufion. It is alfo applicable to every cafe of fever in which the cold affufion is recommended, and thofe may receive much benefit from it, whofe fears or whofe feeblenefs deter them from that energetic remedy. I have not however found its effects fo permanent as thofe of the cold affufion, and I have never feen it followed by the total ceffation of regular fever, as often occurs after the cold affufion. In the hectic fever, however, 9 66 where the actions are lefs ftrongly affociated than in fy- nochus oi typhus, the paroxyfm is fometimes completely extinguifhed by the affufion of tepid water* on the com- mencement of the hot ftage. 1 n the hectic paroxyfm, the heat feldom rifes more than two degrees above the tem- perature of health in the trunk of the body, and three or four degrees on the extremities. By moiftening the palms of the hands and the foles of the feet with vine- gar, its effects may be moderated, for it is from thefen- fation of heat in the extremities, that the ftimulus to the fyftem L chiefly derived; and this practice ought not to be neglected, if the tepid affufion is not employed gene- rally. In all cafes of fever indeed where the burning heat of the palms of the hands and foles of the feet is prefent, this method of cooling them fhould be reforted to; it is uniformly fafe and refrefhing. I have not em- ployed the cold affufion in the hectic paroxyfm. This difeafe generally adheres to a debile fyftem; the body parts with its heat in it eafily; and the Jungs being always affected in the pulmonary hectic, the fudden application of cold to the furface might produce unpleafant, and per- haps dangerous effects on the refpiration. Neither have I tried it in penpneumony, or meazles.f When the affufion of water, cold or tepid, is not em- ployed in fever, benefit may be derived, as has already- been mentioned, though in an inferior degree, by fpon- ging or wetting the body with cold or warm vinegar or water. This application is however to be regulated like the others, by the actual ftate of the patient's heat, and of his fenfations. According to my experience, it is not only lefs effectual, but in many cafes lefs fafe; for the fyftem will often bear a fudden, a general, and a ftimulating ap- * See this fatf mentioned in the Zoonomia, voi. if. p. 296, where a re lation is inferred by Dr. Dai win, of the author's (Dr. Os.) own cafe of hereditary confumption. t (1803) The reader will find fome account of its being acciden*'- 'ikd \n a few cafej of meazles, in the Additional Reports. 67 plication of cold, when it fhrinks from its flow and fuc- ceffive application*. I have alfo ufed the affufion of cool water as a remedy in febrile difeafes, but more frequently in paralyfis, and in other difeafes of debility By the term cool, I indi- cate the temperature from 87 deg. to 75 deg. It ope- * I have purpofely avoided entering on the general operation of cold, in hopes of being better prepared for the fubject at fome future opportu- nity. In the mean time I have continued the ufe of fuch terms as are moft intelligible, and moft confonant to the true doctrines as far as 1 per- ceive them. To fpeak of cold in any form acting as a ftimulus, feems however to fome learned friends, not merely an error, but an abfolute con- tradiction in terms. Heat, they affirm to be the univeifal ftimulus, and cold being merely the privation of heat, mufi in their opinion, always have a fedative operation. As we'll, it is faid, may daiknefs, which is the pri- vation of light, ftimulate the eye, as cold, which is the privation of heat, Simulate the general fyftem. This obfervation, which has more importance with me from the quarter whence it comes, than from any intrinfic weight it poffeffcs, leads me into one or two general remarks. That cold can never act as a ftimulus, was a favourite dogma of the late Dr. Brown. It was a neceffary confequence of his geneial doctrines of life. As he admitted only of two claffes of d fea fes—difeafes of increafed and diminifhed excitement; fo he reduced all remedies to two correfpond- ing claffes—fuch as diminim, and fuch as increafe this excitement. That cold in extreme degrees is a powerful and effeBual fedative is incontro- vertible ; he therefore held that it is fedative in every degree, without be- ing at the trouble to point out the line of temperature below which the term cold is applicable. It wag the character of Dr. Brown to follow his hypothefis into all its confequences, contemning all facts that refted on the teftirrrony of others, and neglecting more than perhaps any man of his talents ever did, to bring his opinions to the teft of experiment. His theory was in his hands the bed of Procruftes. On the operation of cold he was Angularly erroneous. He afferts that cold can never be of fervice in the fevers of the torrid zone; {Elements of Med. vol. i. p. 23.) and the reafon he gives is, that in thofe difeafes there is indirect debility, to which cold muft not be applied. He declares that it never can be of fervice but in fthenic (inflammatory) difeafes, vol. i. p. 103) that for thefe it is the grand remedy ; (p. i$6) that its operation is the fame in meazles, catarrh, and all other inflammatory difeafes, as in fmall-pox; and that " it is fufficient to cure them all!" Thefe affertions are not merely erroneous, they are dangerous in a high degree. Whatever opinion may be entertained of Dr. Brown's fundamental principle—that all the phenomena of life are to he explained by affuming, that the living principle (the excitability) is accumulated and expended in the inverfe ratio of the ftimulation, it will not now be difputed, that he wa; acquainted with only one mode of action of the living principle, that which Dr. Da.win has defcribed under the name of irritation; and that he was wholly regardlefs of the influence of fenlation, volition, and affo- 68 rates as a gentle ftimulant, and may be ufed as a milcie: form of the cold affufion. Like the cold affufion its application fhould be fudden and momentary, when the object is to increafe the tone of the fyftem, or to diffolve a morbid catenation; where it is employed to moderate inordinate heat, it may be ufed more flowly, provided it ciation, fince his time fo fully illuftrated in Zoonomia, and which on every hypothefis muft be allowed to have fuch vaft influence on the motion of life. It was to his difiegarding the action of cold on the fenfations that the error of Dr. Brown is more immediately to be traced. It is not fo eafy to explain why Dr. Darwin, who underftood the laws or fenfation fo well, fhould alfo have difregarded the influence of cold on the fenfe of feeling. He feems to confider the application of cold as merely fubtracting the ftimulus of heat, and thus to be altogether nega- tive ; {Zoonomia, vol. ii. p. 757.) without adverting to that moft powerful fenTatipn, by which great and fudden changes from a higher to a lower temperature are attended, through which the energies of life are roufed into action, and the fedative influence of cold for a time counteracted. Whatever theory we adopt in regard to the origin of caloric in the living body, it feems to me to be in a great meafure owing to the influence of the changes cf the external temperature on the fenfations, that the unifor- mity of the heat of the animal is preferved ; and this view of the fubject is, as far as I can fee, confiftent with the general doctrines of Dr. Darwin. The ftimulating action of cold, though fhort in duration, is powerful in degiee. In the torpor of convulfion, when weaker ftimuli are unper- ceived, the affufion of cold water on the nakid body will often excite the dormant fenfibility, and introduce a new action throughout the nervous fyftem. In the apoplectic ftate brought on by the fumes of charcoal, this remedy is cf all others moft efficacious ; when dogs aie fuffocated in the va- pcii of the Grotto delCani, it is well known that they are recovered by phw.ging them in the adjoining lake. And in other animals, when the laft motions of life are apparently over, the fame application will fometimes, as I have obferved, renew the contraction of thofe fibres that feemed before fixed in death.—This obfervation I hope to illufrrate at fome future op- portunity. Can darknefs ftimulate the eye ? No—Darkness produces no fenfation. Can cold be rendered ftimulating? Surely—After what has been oblerved no one will deny it : unlefs indeed it fhould be faid, that it is not the cold that ftimtilatcs, but the fenfation which the cold produces ; a point that it would be a waite of time to diipute. It is the ftimulant power of cold that renders it fo difficult to employ it in inflammatory difeafes. (See note at the end of chap, xv.) (1803) The above note was written in anfwer to fome obfervations in a letter from Dr. Darwin.—He expteffed an intention of noticing it in the next edition of his Zoonomia, but nothing of the kind is to be found there. 69 does not interrupt the catenation on which refpiration depends.* The practice of giving cold water as a drink in fe- vers, was common among the ancients, and immerfion in cold water they occafionally employed ; but the affu- fion of it on the furface of the body feems to have been wholly unknown. Ablution of the furface with cold water in feverifh difeafes, has been traced under different modifications among the practices of the rude nations of Afia and of Africa by modern travellers, particularly by Sir John Chardin, and Mr. Bruce; but it was firft brought into notice in Europe during an epidemic fever which prevailed at Breflaw, in Silefia, in 1737, as appears from the differtation of J. G. de Hahn, under the title of Epi- demia, verna qua? Wratiftav\am, anno 1737, ajflixit; to be found in the Appendix to the Atla Germanica, vol. x.f While the laws by which the affufion of cold * I borrow this term (catenation) from Dr. Darwin.—It is employed to exprefs a number of actions linked together, nearly in the fenfe of alfo. nation: ihzfympathies, as they are ufually called, are included under this term, and many officiated actions to which the word fympathy has not been applied, as the connexion between the heart and the lungs, the fto- mach and the heart, &c. (See Zoonomia, vol. i. feet, xvii.) t De Hahn fays that he is the better able to defcribe this difeafe, as he himfelf was feized with it; and was cured by " peregrina ilia multis vifa medendi methodus." He begins with an account of the caufes of the epi- demic—That firft mentioned is the ftate of the weather. In the month vt May 1786, after a very promifing fpring, the weather became wet and cold, and the fall of rain was fo confiderable during June, July, and part of Auguft, as to lay a great part of Silefia under water. The wind blew chiefly from the north-weft.—The harveft was almoft entirely deftroyed. In confequence a famine prevailed throughout the province, of which the au- thor gives a dreadful account, and this he mentions as the fecond caufe. The third caufe was the vitiated air. The unburied carcaffes of perfons flam in battle were fuffered to putrefy in the atmofphere, and the ftagna- tion of the waters in the low grounds filled it with marfh effluvia. Even the cattle fuffered feverely from this ftate of the air, and from the want of pure water to drink. The epidemic began in the enfuing fpring. He gives a number of cafes. The firft is that of a farmer in the neighbour- hood of the city, of forty years of age. " Comites febris erant fubitus virium lapfus, capitis & praecordiorum dolor gravis, fluxio alvi, pervigi. Hum, inquies, delirium. Quae infuperabilia morbi fympromata excipiebat die undecima his ipfis infuperabllior obitus." The fecond cafe he men- tions occurred in the city. It is that of a delicate woman of thirty years 7° water ought to be regulated were not underftood, the ufe of the remedy muft have been extremely hazardous, and the fatal confequences of its improper application, of 3ge, previoufly afflicted by fevere misfortunes. The fymptoms were as follows. " Subito elanguida febriebat. Doior capitis ilhco atrox. Sitis, & fecundo die, impoituni mcnfes. Exin vomitus bilis, alvufque biliofa. Sputa vifcida. Syncopticti8 rigor. Ardor partium internus. Lmguse quafi candenti ferro compieffa?, ficca giabnties & leftrictio. Vox arentibus faucibus nulla. Angina fine tumoie peflima. Repetebant in- terdum tenacis pituita? vomitus. alvique fluxio. Os fine medela ficcum. Iactatio. Stipinus torpor. Mors inter ccnvuifione-; gemibunda " The author proceeds to detail four other cafes fimilar to tht above, which alfo terminated fatally. Two females who caught the infection, efcaped in confequence of critical eruptions. At length the alarm became general. The attention of the magiftrares was roufed, and from a ftrict inquiry it was found, that more than double the ufual number of deaths had occurred at Bieflaw in that year. All the ufual methods of practice were of no avail. Whether bleeding was em- ployed or abftained from, the difeafe was equally mortal. In this diftrefs Dr. De Hahn determined to try the effects of the external ufe of cold water. The firft cafe in which it was employed, occurred in the month of April j it is related as follows. " Mercator xxxii annos natus, floridus natura, mox febriens, capitifque dolore & naufea afftctus. Permittentibus id viri- bus, altera die mittebamus fanguinem, qui inflammatorius. Vefpere vomebat aeger, tertia die maculofus. Macula: morillis aemulae, incon- ftantes. Mador. Mox prascordiorum intolerabilis dolor & delirium. Quafi ex temulentia vacillans extra lectum vagabatur aeger. Oculoaltero dilatato, altero connivente, utroque gramiofo &c caligenofo; lingua laevi, arida, candente; fputo refinofo; mini biliofa.'"—The ufual remedies failing, on the eighth day they had reeourfe to ablution. " Turn ad ex- ternas illas humectations confugiebamus, indefeffa opera fpongiis omnem corporis ambitum demulcentes. Id confequebamur, ut fenfim fputa refi- nofa fierent magis mobilia; ut flaccida et fufca facies confpiceretur magis turgidula; utfeliciusprocederet blandusmador ; ut refipifceieret, hactenus vel loquax nimium, vel taciturnus ex delirio aeger." The author then re- lates a cafe of a fimilar nature, in which, the ablutions being rejected, the patient died. Next follows the cafe of a lady, a relation of his own, forty- three years of a^e, whofe fymptoms appeared of the moft dangerous nature. In this cafe the attack was fudden. " Inter domefticas occupationes quafi conqnaflata concidebat. Facies primo momento Hippociatica; artubusgla- cieperfufi* & tremulis. Horroi repeiitu^ ad quemvis aeiis tiactum. Vomi- tus poft quaevis ingefta. Abdominis turgor. Videbatur mihi advolanti non morbo corripi aegra, fed fiderata mori, vixque amplius cum morte colluc- tari. Pharmaco, ob vomitus, non erat locus; neque vense ftctioni, ob algida & emarcida membra. Die ada, jugj abluitione artuum glacies diffluebat inter gemibundos angores. Sitis tandem invitabit potum. Ca- lorem excipiebat aeftus. Clyfma folvebat partes abdominis internas. Quar- fa die, magis fibi confeia aegra caput quafi a percuflione dolere conquere- batur. * * * Octava demum die, certa rediturae fanitatis fpes, duorum tandem menfium confirmata." The author next relates the cafe of a man of fixty-four, whom he at- tended, with two other pbyficians, and on whom the affufion of cold water, 7l we can eafily believe to have prevented its gaining any ground on the continent, or its having been adopted in Britain. Thefe laws are now, 1 hope, afcertained by or ablution of any kind, does not feem to hive been tried. This perfon died on the ioth day, and our author himfelf was immediately after feized with the difeafe, having probably caught it from this patient. He was in his 44th year. " Die imo, Perfenferam inter vix fuperabiles labores, infeftum aliquamdiu nuchae dolorem. Hie ifto mane iblito ferventior, febrem epidtmicam invitabat abl'que piaevio horroris fenfu. Saevus ille dolor ex nucha ortum ducens—tutum tunc ambiebat caput. * * * Fer- vebat caput, frigentibus pedibus, fpafmo ad abdomen rigidis. Auges- cente de momento in momentum dolore, horror aderat ad quemvis aeris attactum. Languor mox ab initio extiemus. Nox inquieta Sc £udans. xdo, Oc.di graviffime dolentes * * * 3tio, Parca mane remilfio doloium, mox intenfiorum; febre, praevio tempore, aucta. Nox clamofo nuchae & capitis cruciatu atrox. 4to, Pott hanc dies nocte pejor. Pedum gla- cies nondumegelata." Thefe fymptoms increafed daily. Onthefeventh day theie was great fubfultus tendmum, and the whole body was covered with petechias. In .hefe circumftances reeourfe was had to ablution with cold water. «« Ab hac die abluitio frigida univerfalis in ufum vocata cum antea particularis tantum obtiniffet. 8vo, Pulfus tremulus obl'ervatur. Gemitus a doloium ferocia perennis. omo, Vomitus grumum cruori* emoliebatui. lomo, Obtinebat tunc rerum ab aliquo mentis deliro ftu- pore incuria. nmo, Sudor, armiftitium aliquot horartim producens, opportuno corticis ufui locum concedebat, cum jwm exitialis languor quss- vis peflima minaretur. Loquela difficilis& balbutiens. Angina apthofa. Stridor dentium. nmo, Rifus fardonicus. Spafmi cynici. * * * Id interim confequebamur corticis ufu, ut quotidiana exacerbatio tardius, & die decima quarta, quae tota comaiofa fuerat, fub ncctem demum ingru- erit. Sed gravitate tarditatem compenfabat, violenti frigore totum corpus quatiente. Mox algidus aderat fudor, deficiente loquela"; demiflacitra vo- luntatis imperium urina." Fiom this apparently del'perate ftate, De Hahn, however, recovered, and chiefly, as he apprehends, by the ablu- tions of cold water, which were employed even in this advanced ftage of the fever. Almoft from the beginning of the fever he indulged freely, according to the plan he had followed with others, in liquids, confuting chiefly of water, rendered giateful and cooling by the addition of lemon juice, nitre, &c. and every night he took a moderate dofc of opium, from which he found the greateft benefit. From all heating alsxipharmics he entirely abftained, having the greateft repugnance to them. On the fe- venth day, the general ablutions with cold water were begun. The me- thod employed feems to have been that of fponging the I'm face, and this appears to have been continued f~r fome t me together. The effedts are def'cribed as follows. " Sanctcque teftor, nuilquam non refici ad breva temporis momentum languentes marcidae cutis fibras me perfenfiffe. Suc- cedebat, repurgatis hac ope poris, pelpiratio liberior, ac fudor modeftus; videbanturque cutis obturacula promptius fpi.ngia remota, qu.un phar- maci interni viitute. Recreabat prastciea hiantia & purum aeiem fitientia Cutis ora, liberior aeris accefius." This account of the effecls of thr practice, correfponds with our experience at piefent. Dr. De H.hn found thr advantage of a plentiful fupplvof frefh air, at that t:me little under- 72 ample experience, and practitioners will, I truft, find themfelves directed in fafety in the future ufe of this powerful remedy. flood throughout Germany or Europe, and he fecured it by keeping his win - dows open. He changed his bed-clothes and linen frequently ; and he oc- cupied one bed during the day, and another during the night, a practice which moderated the heat, and often produced great refreshment. This practice deferves indeed to be followed whenever it can be done with conve- nience. Experience convinces me that it always produces much comfort under feverifh heat and irritation, and that it often procures tranquil fleep. Where a change of bed cannot be obtained, the method of Dr. Fianklin, of expofing the body to frefli air, and ventilating the bed-clothes, ought to be reforted to. De Hahn took the bark on the nth day, and found it very grateful to his ftomach, and agreeable to his fenfations. That day he took five drachms of the powder. On the izth, he took four drachms ; on the 13th, three only ; and on the 14th, only one; his relifh for it ha- ving gone off. The baik feemed to moderate his fymptoms, which returned with violence on leaving it off, and on the 15th day he found himfelf on the point of death. At this very time however he perfifted in the cold ablutions, and to them he afcribes his recovery. " Juges iliac abluitiones, quibus hucufque recreatus fueram, ea ipfo die, qua mori videbar, non negiigebantur; licet enim totus algidus algido fudore perfunderer, non fecus ac liquefactae glaciei immerfus, frigida tamen abluebar; maritofer- vitura chariflima conjuge lethales madores ocius deluente." From this time the fymptoms became lefs violent, but his recovery was flow and dif- ficult. On the 18th day he was ftill delirious, and fyncope came on when he attempted to get out of bed. His appetite, however, began to return, he had copious fweats and fell into profound fleep. On awaking he felt a great avenion to noife, and every thing appeared new and extraordinary. On the 36th day cholera came on, but was fubdued. On the 48th there was a defquamation of the fkin, and a falling off of the nails. He con- cludes this account of his own cafe in the following words, " Morbi tandem reliquiae menftrua equitatione feliciter fubactae." De Hahn was attended by his father, alfo a phyfician, under whofe direction the ablutions were performed, and by whom the greater pait of the fymptams muft have been recorded. In confequence of this fuccefs cold ablutions were employed with others, and many were faved by them in circumftances apparently the moft defperate. It is evident from this abftract, that De Hahn was not regulated in his ufe of external ablution with cold water, by rules fimilar to thofe which I have ventured to lay down from feveral years experience. Inftead of pouring the water over the naked body, he applied fponges foaked in cold water to every part of the furface in fucceffion, and feems to have continued the application for fome time together; in my judgment the leaft effica- cious, as well as the moft hazardous manner of ufing the remedy. He does not feem in general to have ufed the ablutions till the eighth or ninth day of fever, and till the cafes were growing defperate from the failure of other means. At this advanced ftage, the ablutions, as might be expected feem to have been of very inferior efficacy. Yet in 'he Angle cafe. ;n v.-i.^l' 73 The affufion of tepid water in febrile difeafes was not unknown to the ancients, though feldom employed by them.* It is, I apprehend, new in modern practice, and will be found an important addition to the lift of our remedies. The effects differ confiderably from immer- fion in the tepid bath, as will be more fully explained in fpeaking of that remedy. Though the affufion of from the impoflibility of the patient's fwallowing medicines, ablutions were ufed on the fecond day of the fever, the recovery was fpeedy ; it ap- peared certain on the eighth day; and this might have encouraged an earlier trial of the fame practice in other inftances. But what appears to me moft furprifing, is, that he does not feem to have been regulated in the ufe of this remedy, either by the actual heat of the patient or his fenfations of heat. In his own cafe he exprefsly declares, that the cold ablutions were ufed on the 15th day of the fever, when he was fhivering with cold, and covered with cold fweat; circumftances under which I fhould pro- nounce it to be in the moft extieme degree dangerous. Whether my re- ftrictions as to the ufe of the cold affufion, and the application of cold in general to the body, be too fevere, future obfervations muft decide; but from a general review of the incautious practice of De Hahn, I am not fuiprifed that his boafted remedy, is, fo far as I can learn, no longer in ufe, eiiher in Silefia or in any part of Germany. Befides ablution, clyfters of water were found ufeful in this epidemic, and water was ufed copioufly as a drink. Eruptions of a fuppofed critical nature frequently appeared. This fever carried off three thoufand perfons in Breflaw and its vicinity. The means of making this abftract have been fumifhed me by a friend at Edinburgh, who copied for me the greater part of the memoir of Dr. De Hahn, from the 10th vol. of the Ada Germanica, in the College Library ; in my firft edition called Ada Not. Cur. after Dr. Cullen. (1803.) In my laft edition this note was printed very inaccurately, owing to an accidental circumftance—the quotations from De Hahn are now I hope given with fufficient correctnefs, though I have not had an opportunity of infpecting the printed work. The abftract of this differta- tion in Sauvages is imperfect and incorrect, not being taken from the original work of De Hahn, but from the Review of it in the Journal de Medicine for 1757. See Nofologia Method: Tom. i. p. 334, 4/0 edition. • Some traces of its ufe in fever are to be found in Celfus. " Quidam " ex antiquioribus medicis, Cleophantus, in hoc genere morborum, " (tertian intermittents) multo ante acceifionem caput a;gri multa ca- " lidi aqua perfundebat, deinde vinum dabat. Quod quamvis pleraque " ejus viri pra?cepta fecutus eft Afclepiades, recte tamen piaeteriit, eft " enim anceps," Celfus, lib. iii. cap. xiv. This ufe of the tepid or warm affufion is altogether different from what I propofe, and was not only, as Celfus fuppefes, a doubtful, but probably an injurious practice. For by chilling the body, it would difpofe it to the acceflion of the paroxyfm. The ufe of the tepid affufion as now propokd, may fairly be confident as a new practice, IO 74 tepid water was little in ufe as a remedy, it was familiarly practifed as a part of their daily regimen, by the Greeks and Afiatics, in the earlier periods of their hiftory. That the Greeks in later times, and after them the Romans, immerfed themfelves in the baths to which they were fo much devoted, is certain ; but in the heroic age of Greece, the affufion of tepid water feems to have been the mode in which this luxury was enjoyed. Abundant proofs of this are to be found in Homer, particularly in the Odyffey, that admirable record of an- cient manners. Venus, after her public difgracc, is de- fcribed as flying to the groves of Paphos, were fhe is laved by the Graces, and the improvement derived to her beauty is recorded in a ftrain of poetry worthy of the fubject. {Odys. lib. viii. /. 362 to 367). Ulyffes isrepre-^ tented as laved by attendant nymphs in the court of Al- cinous, and in the ifland of Circe the whole procefs of heat- ing the wafer, and pouring it over the naked hero, is par- ticularly defcribed.* On thisoccafion alfo, nymphs ad- miniftered to him, who after the ablution anointed him all over with oil; a fervice well calculated in every refpect to increafe the pleafure, and to diminifh the rifque of the tepid affufion. The Romans under their Emperors, carried the fyftem of bathing to a height of luxury and expenfe which it never reached in Greece or Afia, as the ruins of their magnifi- cent Balnea prove to this day ; and the affufion of warm water was one of the methods by which they diverfified this favorite gratification.j- * 'Odys. lib. x. /. 358, &c. compare this with the bathing of Telemachus «D lib. xvii. /. 85, &c. f See Hieronymi Mercurialis de Arte Cymnafi ; lib. i. p. 44 and 45. 7$ CHAP. XI. Of the Internal Ufe of Cold Water in Fever. BEFORE I conclude the account of my experience of the ufe of cold water in fever, it will be necef- fary for me to fay fomething of its effects when fwal- lowed, on the ftomach, and through it on the fyftem at large. Among the ancients the internal ufe of cold water in ardent fevers is recommended by Hippocrates, Galen, Celfus, and moft of the celebrated phyficians whofe works have come down to us: among the mo- derns, that extraordinary man, Cardanus, wrote a dif- ferution in its favour, and to pafs over a multitude of inferior names, Hoffman, though with fome reflections, recommends it, not in fever only, but in various other difeafes.* In our own country it was propofed as an al- moft univerfal remedy by Smith, and a treatife has been written on it under the title of Febrifugum Magnum, by Dr. Hancock. In Spain and in Italy the ufe of cold water in fevers, obtained in the beginning of this cen- tury, a greater and more general reputation than in any of the other countries in Europe, and at one time, feems to have fuperfeded all other diet, as well as medicine. This treatment was celebrated under the title of Diaeta Aquea, and an account of it may be found in the 36th volume of the Philofophical Tranfactions, by Dr. Cy- • Hoffmanni Opera, vol. i. p. 479. 7* rillus, a profeffor at Naples, to which the reader is re- ferred. Befides the internal ufe of cold water, he men- tions the advantage of laying powdered ice or fnow on the bodies of the fick. Neverthelefs, the propriety of giving cold water in fevers has been difpuied by men of high character, and particularly by the celebrated Boerhaave. His doctrine, that a lentor in the blood is the caufe of fever, led him to infift on the ufe of warm drink, and the danger of cold; and his commentator Van Swieten, though he allows cold drink in fome inftances, yet in general ar- gues againft it.* Thefe learned theorifts prevailed in their day over the voice of nature, and the precepts of Hippocrates and Hoffman.—In the writings of Pringle, Cleghorn, and Lind, we find little or nothing on-the fubject, though they wrote exprefsly on fevers; Dr. Cullen mentions cold drink, but gives no opinion on the propriety of its being ufed, and certainly did not re- commend it in practice. He was even doubtful of the extent to which cold air might be admitted.f On the whole it may be afferted, that the ufe of cold drink in fever is contrary to modern practice, and that where it is occafionally given, it is adminiftered with caution, and rather permitted than enjoined. It is not however to the doctrine and precepts of Boerhaave alone, that the difufe of cold drink in fevers is to be imputed. The propriety of giving it freely has been at all times controverted, not on the ground of theory only, but from experience of the dangerous, and fometimes fuddenly fatal effects of large draughts of cold liquids, various inftances of which have been recorded from the earlieft periods of medical hiftory. While therefore fome phyficians have prohibited the ufe of cold '• See Boerhaavii Aphorifm. Sect. 743, with the commentary of Van Snvieten. f See his firft Line6—cure of fever. 77 drink in fevers altogether, thpfe who have recom- mended it from experience of its falutary effects, have introduced various cautions as to its exhibition, founded on certain theories, generally fallacious, on the manner in which its deleterious influence is produced. To de- tail the various opinions that have prevailed on this curi- ous and important point, would be to add another chap- ter to the ample records of human errors. That the danger arifing from cold drink depended oa the great difference between the temperature of the liquid and of the body, and that it is therefore to be prohibited when the heat of the body is very great, is an opinion very generally received by the moderns: and among the ancients, though their doctrines were lefs erroneous, yet while the means of afcertaining the real heat of the living body, and the changes it undergoes, were un- known, it cannot be expected that they fhould have ar- rived at the truth on this important fubject. The effects of cold water as a drink in fevers, I was naturally led to examine by my experience of its effects as an external application. I have made this examina- tion with the thermometer in my hand, and with all the attention in my power; and the following refults, which will fave the reader the fatigue of reading the particu- lars of various cafes and experiments, feem to me to contain all the information neceffary to direft our prac- tice. i. Cold water is not to be ufed «s a drink in the cold ftage of the paroxyfm of fever, however urgent the thirft. Taken at fuch times, it increafes the chillinefs and torpor of the furface and extremities, and produces a fenfe of coldnefs in the ftomach, augments the op- preffion on the prsecordia, and renders the pulfe more frequent and more feeble. Its effects in all thefe ref- pects are fimilar to the affufion of cold water on the fkin in the fame ftage of the paroxyfm, as defcribed in pages 29 and 43, though inferior in degree. If the thirft is 7» gratified in the cold ftage of the paroxyfm, it ought to be with warm liquids.' i. When the hot ftage is fairly formed, and the fur- face is dry and burning, cold water may be drunk with the utmoft freedom. Frequent draughts of cold liquids at this period, are highly grateful; they generally di- minifh the heat of the furface feveral degrees, and they leffen the frequency of the pulfe. When they are at- tended with thefe falutary effects, fenfible perfpiration and fleep commonly follow.—Thef- effects are fimilar to thofe produced by the affufion of cold water on the furface, as already defcribed, but inferior in degree alfo. Though various cafes are on record of the paroxyfm of fever being diffolved by cold water, drunk in this ftage of the difeafe, my experience does not furnifh me with any inftance of this kind.* Indeed fince 1 became ac- quainted with the extraordinary efficacy of the affufion of cold water on the furface, 1 have not trufted the fo- lution of the paroxyfm to its internal ufe. I have how- ever employed cold drink when neceffary as an auxiliary. Throughout the hot ftage of the paroxyfm cold water may be fafely drunk, and more freely in proportion as the heat is farther advanced above the natural ft andard. It may even be drunk in the beginning of the fweating ftage, though more fparingly. Its cautious ufe at this time vvill promote the flow of the fenfible perfpiration, which after it has commenced, feems often to be retard- ed by a frefh increafe of animal heat. A draught of cold water taken under fuch circumftancrs will often re- duce the heat to the ftandard at which perfpiration flows * See Alpinus. Med. Meth. lib. ii. cap. 3. After reciting the effects of cold drink in dimii.ifhtug heat and thirft, and exciting profufe perfo- rations and large difcliarges of urine, he concludes, Mirabile efi, quomodo tale praeftdiuri, basjebres expugnat; nam execrelionibus, quas aquafuf- citat, haejebres finiunter. According to the fame author, this practice was followed by the Egyptians, See lib. ii. cap. 15. The pernicious effects of cold drink during profufe perfpirations was known to the ancients.—See Celfus, lib. i. cap. 3. 79 more freely, and thus bring the paroxyfm to a fpeedier iffue. 3. But after the fenfible perfpiration has become ge- neral and profufe, the ufe of cold drink is ftriflly to be forbidden. At this time I have perceived in more than one inftance, an inconfiderate draught of cold water, produce a fudden chillinefs both on the furface and at the ftomach, with great fenfe of debility, and much op- preffion and irregularity of refpiration. At fuch times, on applying the thermometer to the furface, -the heat has been found fuddenly and greatly reduced. The proper remedy is to apply a bladder filled with wa- ter, heated from 110 deg. to 120 degrees, to the fcrobi- culus cordis, and to adminifter fmall and frequent dofes of tincture of opium, as recommended by Dr. Rufh, By thefe means the heat is fpeedily reftored. This effect of cold water ufed as a drink during pro- fufe perfpiration, is precifely analagous to the affufion of it at fucH times on the furface of the body, a practice known to be of the utmoft danger, and enumerated by Hoffman among the caufes of fudden death. Inveniun- tur in amplijjimo regno natura plura qua brevi tempore nocent ac perimunt, ut aqua frigida corpori fudore difflu- enti immoderatius fuperingefta. Vol. i. p. 194. The pernicious effects of cold water applied internal- ly and externally during prdfufe perfpiration, depend on the fame caufes, namely, that perfpiration itfelf is a cooling procefs, under which when profufe, the heat of the body, whatever its actual ftate may be, is finking; that under fuch circumftances, we find as a matter of fact, that it parts with its remaining heat more eafily; and on the fudden application of cold, that this heat finks to a degree which diftyrbs, and fometimes wholly interrupts the actions on which life immediately de- pends. Bo Thus then we may fafely adopt the fame general rules for the ufe of cold water in fever as a drink, that have already been laid down for its external application. It may be ufed as a drink, in fevers, at any time, when there is no fenfe of chillinefs prefent, when the heat of the furface is fteadily above what is natural, and when there is no general or profufe fenfible perfpiration.* Though we have arrived at thefe conclufions, the effects of cold water ufed as a drink have not been in- ferred from its external application, but made the fub- ject of feparate inquiry. Yet, that in the one cafe, and in the other, they fhould be fimilar in kind, though different in degree, will be expected by every one ac- quainted with the laws of the animal economy, and par- ticularly with the fympathy that fubfifts between the ftomach and the furface. I have only to add, that in our common contagious fever, when I have ufed the affufion of cold water, I have feldom found it neceffary to employ it largely as a drink, and my experience of its effects when drunk in large quantities, has been chiefly confined to thofe cafes, where the fears or prejudices of the patients, or their friends, have prevented our hiving reeourfe to the more powerful method of affufion. For, however burning the thirft may be, it is fpeedily abated, and even remo- ved, with very little drink, and often without any, by the fuccefsful ufe of the affufion on the furface. Though the affufion in general fuffices in our contagious fever, yet where cold water is employed in the dreadful fever of Philadelphia and the Weft Indies, it is probable, that its internal and external ufe fhould be combined; a point that muft be determined by the actual heat of the patients, meafured by the thermometer, and by their fenfation of heat; circumftances of which it is to be regretted that we have as yet no accurate information. * See page 29. Si CHAP. XII. Of the Difeafe that arifes from drinking Cold Liquids, or ufing the Cold Bath, after fevere Exercife. IT is here natural to inquire how far the fatal effects pro- ceeding from drinking cold water, not in fever, but in cafes where the fyftem has been extremely heated by bodily exertions, (of which the records of medicine af- ford fomany inftances), are to be explained on the prin- ciples already laid down. If they are explicable on thefe principles, we ought to be able to fhew, that they have occured in fituations where the fyftem, after having been much heated and enfeebled by fevere exertions, is lofing its preternatural heat from profufe fweating, and in general alfo from the ceffation of the exertions by which this heat was originally produced. Here two powerful caufes combine to cool the body, and if under their operation, a fudden application of cold is made either to the ftomach or the furface, the living power will, we know, refill it faintly, and the fatal confe- quences be accounted for. i. In my own experience this fudden death has oc- curred once only, and that many years ago. It was in the cafe of a young man who had been engaged a long time in a moft fevere match at fives. After it was over, he fat down on the ground, panting for breath, and co- vered with profufe perfpiration. In this ftate he called ii 82 to a fervant to bring him a pitcher of cold water juft drawn from a pump in fight. He held it in his hand for fome minutes, but put it to his head as foon as he had recovered his breath, and drank a large quantity at once. He laid his hand on his ftomach, and bent for- wards ; his countenance became pale, his breath labo- rious, and in a few minutes he expired. Various me- thods were employed to reftore him, but in vain. 2. The following cafe refembles very exactly that juft given. Blafius, Senenfis, familiaris nofter et con- difcipulus, dum longiufculo tempore fub ardentiffimo fole pila lufu incaluiffet, nee fudore adhuc aut fatigatione remiflis, in fubterraneum locum ubi vinaria erat cellula, defcendiffet, frigidiffimi vini calicem haufit; quo epoto, ftatim defecit. Benevent. cap. 17. De abditis. 3. Elegans & optima ftatura juvenis Romanus, cum pild luderet, et fudore refperfus, ac totus madidus, & fatigatus ad puteum, pro fiti arcendd veniffet, exhauftd frigidd recens per caldarium extracid, illico in t err am cecidit C5? sbiit. 4. Alterum novimus ex Us, qui in campo negotiantur, qui quum non minus corporis totius adapertis poris madi- dus domum reverteretur, cyathum frigidioris aqua ebibit, et mortuus fiuit. Anat. Lufit. curat, med. cent. 2. cu- rat. 62. 5. Forreftus relates, that in the year i$44> Valerius Cordus, a young man of great learning and talents, went during the heat of the dog-days, to collect plants among the Florentine mountains. Exhaufted with fa- tigue and thirft, he incautioufly drank of a cold fpring which iffued our of one of the hills, and was immedi- ately feized with a fever, of which he died; but the fymptoms of which he has not recorded, P. Foreftus, lib. i. Scholia ad cbs. 13. 83 6. Scaliger relates the cafe of a reaper, who, {loop- ing down to drink at a fountain after fevere labour, in- ftantly expired. Scaliger de Subt. ad Cardan, exer. 13. 7. In Heifter's obfervations, a cafe is related 6f a young man, who, about the Chriftmas feafon, had been playing and dancing at a Mill with fome young women, and had eaten greedily of fome hot buttered cake. Af- ter this, being extremely thirfty, he took a large draught of fome cold water mixed with fnow. An inflamma- tion in the ftomach followed, terminating in mortifica- tion, of which he died. Heifter's Med. &c. Obferva- tions tranftated by Wifeman, p. 17. 8. Villanum quendam nobis familiar em novimus, qui meffis tempore, anno 1597, exhauftus viribus, et totus fitibundus pros nimio folis ardore, domum rediens, cum in magnay quantitate, adfitim explendam, gelidam (aquam) bibiffet, exanimatus mox juxta puteum cedidit, ac intra tres horas animam expiravit. Georgius Graffeccius in Theatro Anatomico. Thefe relations are chiefly taken from the collection' of Schenck—they might be greatly enlarged, and I have collected a number of fimilar cafes ; which it were a te- dious and an ufelefs tafk to detail. In all of the cafes which I have confulted, as well as in thofe I have related, three circumftances are either expreffed or may be clearly inferred—1, The body had been previoufly heated be- yond the temperature of health, by exercife carried to fatigue. 2, To this violent exertion a ftate of reft had fucceeded. 3, A profufe perfpiration had taken place. So far our reafoning is fupported; but as thefe points are of the utmoft confequence in explaining the opera- tion of cold on the human body, and as direct experi- ments are attended with extreme hazard, the reader will excufe me if I attempt to illuftrate them by fuch evi- dence as hiftory may incidentally afford. 84 i. In Quintus Curtius, (lib.vu. cap. $.) an account is given of the march of the army of Alexander the Great in purfuit of Beffus, through the country of the Sogdiani, which is reprefented as deftitute of water, fte- rile, and covered with fcorching fands. The intolera- ble heat, fatigue, and thirft of the foldiers, in their march through this burning defert, are defcribed with all the florid eloquence of the hiftorian. At length, fainting under their toils, they reached the banks of the river Oxus, where by indulging large draughts of the ftream, Alexander loft a greater number of his troops than in any of his battles. Sed qui intemperantius hau- ferant inter clufo fpiritu extintli funt; multoqus major horum numerus fuit, quam ullo amiferat pralio* 2. A fimilar ftory is related by Appian—Appianus Alexandrinus de beilis civilibus, lib. v. tradidit Cornifi- cianos milites a Pompeianis pugna fatigatos & aftuantes fontanam aquam avide bibentei, ex Us plurimos emortucs. Marcel. Donat. lib. iv. cap. 6. Hift. med. mirah. * The whole particulars of this march as defcribed by Quintus Curtiu.;, are very interefting. The defert, which contained not a drop of water, was foui hundied Stadia aciofs—(per quadringenta fiadia ne modicus qui- dem humor exfifiit) that is, upwards of toi ty-fix Enghfh miles. They began their juimey in the ni^h', directing their courfe by the ftars, and for lbme time their march was toleiable, being refrefhed by the dews of the night, and the coolnefs of the dawn ; but when the fun rofe, the heat became troubiefome, and as the day proceeded, moft oppreffive; it was equally painful to fhnd ftill or pioceed. After a day < f dreadful fatigue, the vanguard of the army, and Alexander himfelf, reached the Oxus to- wards evening; and fuch as were ihtmfelves refrefhed, were employed in carrying water back to the fainting troops behind. As they arrived in fucceffion on the banks of the river, it may eafily be fuppofed that they drank without moderation, and hence the diftruction that enfued. It was on this occafion that Alexander difplayed his magnanimity, in lefu- fing the cup of water biought to him z> he advanced, becaufe it was not fufficent both for him and his companions ; and th.it he gave a proof of hic genius, by ordering fires to be kindled on the high banks of the Oxus, not merely to direct his way-worn foldiers through the darknefs, but to animate the r fa nti. g exertions by a profptit of ihe end of their toils. Plutarch alludes to this ftory, but does not relate it fully. I fear it is not to be found in Arrian. A fimilar diftrtfs is mentioned by him {lib. vi. p- 4^5) t0 'iave occurred in Alexander's march through the defei ts of the country of tin- Ged'ofi, who inhab ted the fouthern part of the Perftan, empire, on the Ihores of the Indian ocean. 85 3. A difafter of the fame kind is recorded to have occurred to the Chriftian army in the holy wars. Gu- lielmus Tyrius, lib. iii. c. 16. fcribit, Chriftianum ag- men Pifidiam ingreffum, regionem arentem ex? inaquofam, tandem invento fluvio, avide bibiffe; quad quidem, qui largius aquam frigidam ingurgitaverunt, fitis difcrimen evadentes, mortem in aquarum opulentid reperere. Thefe hiflorical relations fupport very fully the doc- trine I have already laid down. The cautious reafoner may not, on a hafty confideration, be inclined to reft with much confidence on this fort of evidence; but on reflection he will fee that it is entitled to confiderable authority; becaufethe facts are in their nature not liable to be miftaken, and becaufe they are not likely to be mifre- prefented. It is alfo entitled to much weight, becaufe it is not given by thefe hiftorians in fupport of any par- ticular doctrine; and becaufe the experiment having been made on fuch numbers of perfons at once, it ac- quires an authority hardly to be afcribed to folitary ca- fes, however accurately detailed. Thefe confederations induce me to lay much more ftrefs on evidence of this kind, than on the precepts refpecting the effects of cold drink to be found in medical authors, ancient or mo- dern. Neverthelefs I have looked into the greater part of the ancients on this point, (for among the moderns there is not much on the fubject), and have found nothing, that fully confidered, invalidates the con- clufions I have laid down. Of the ancient phyficians, the moft copious on the ufe of water, in all its forms, is Galen. He not only ufed cold drink, but immerfion in the cold bath, in burning fevers, with extraordinary fuccefs. His rela- tions appear to me, in general tedious and obfeure, but not deftitute of truth; and the wearinefs of perufing him, is occafionally relieved by the pleafure of refcuing a fact: that was buried under maffes of falfe theory. 86 The reader who would confult him on this fubject may ufe the references below.* In the firft volume of Medical Inquiries and Obfer- vations, publifhed by Dr. Ruth of Philadelphia, 1789, an account is given of the " Diforder occafioned. by "drinking cold water in warm weather," which fre- quently occurs there, " Three circumftances," he ob- serves, " generally concur to produce difeafe or death " from drinking cold water. 1, The patient is ex- (t tremely warm. 2, The water is extremely cold. And " 3, A large quantity of it is fuddenly taken into the " body. The danger from drinking cold water is'al- " ways in proportion to the degrees of combination " which occur in the three circumftances that have been " mentioned." p. 151. Dr. Rufh goes on to ftate the fymptoms of this difeafe, which are, I apprehend, gi- ven with accuracy. His meihod of cure my experience neither authorifes me to confirm nor oppofe. " I know " but one certain remedy for this difeafe, and that is " liquid laudanum. The dofes of it, as in other cafes of " fpafm, fhould be proportioned to the violence of the " difeafe. From a tea-fpoonful, to near a table-fpoon- " ful, has been given in fome inftances before relief has " been obtained. Where the powers of life appear to " be fuddenly fulpended, the fame remedies fhould be " ufed which have been fo fuccefsfully employed in re- " covering perfons fiippofed to be dead from drowning." To this I would add the application of a bladder filled with water, heated to no deg. or 115 deg. of Fahren- renheit, to the pit of the ftomach, from which 1 have feen powerful effects in reftoring the vital heat. But while I do not diffent from Dr. Rufh's practice, I cannot fubfcribe to his notion of the caufes of this difeafe, or to the method of prevention founded on this notion. * Vol. i. 23. B- Vol. ii. 78. C. Vol. vii. 70. A. and forwards throughout the volume. I quote from the Latin edition in folio, publifli- ed at Venice, 1656. 87 Dr. Rufh feems to entertain the popular opinion on this fubjecl: the body is extremely warm, the water ex- tremely cold, and a large quantity is introduced fuddenly. He apprehends the danger to arife from the great differ- ence between the temperature of the body, and of the water taken in. As a means of prevention he therefore propofes to fuch as cannot be retrained from drinking cold water when preternaturally heated—i, To grafp the veffel out of which they are about to drink for a minute or longer with both hands, that a portion of heat may be abftracted from the body and imparted to the cold liquor. 2, If they are not furnifhed with a veffel to drink out of, but obliged to drink at a pump or a fpring, always to wafh their hands and face previoufly to drinking, with a little of the cold water. " By re- ceiving/' lays he, " the fhock of the water firft on thofe " parts of the body, a portion of its heat is conveyed " away, and the vital parts are defended from the action " of the cold." The fact however is in my mind perfectly eftablifhed, that there is no fituation in which the application of cold to the body, whether to the furface or the ftomach, is fo fafe, or in general fo falutary, as when the heat of the body from whatever caufe, is preternaturally great, pro- vided that the body is not already in a ftate in which it is rapidly parting with this heat, and no difeafe has taken place in the general fenfibility, or in the ftructure of any of the parts ; and that where the body is preter- naturally heated, the degree to which cold water may be drunk, may be always decided by the fteadinefs of' the fenfation of heat, and the tenacity with which the pre- ternatural heat is actually retained. Thus, in continued fevers it may be drunk to a greater extent, than in the hot ftage of intermittents, becaufe the heat is more firmly retained; the profufe perfpiration not being at hand, by which the febrile heat of intermittents is carried off. The ancients who gave cold drink largely in continued fe- 88 vers, were doubtful of its ufe in intermittents.* It may however be given (as I have already ftated) with great fafety in intermittents, provided it be taken in the time that intervenes after the hot ftage of the paroxyfm is fairly eftablifhed, and before the fweat that follows it, has be- come general and profufe. As however it is only in that interval that it can be given in intermittents with ad- vantage or fafety, we can eafily underftand, that the ill effects arifing from its being accidently drunk in the cold, or the fweating ftage of the paroxyfm, (in both of which the thirft often demands liquids), may have pro- duced the doubts which fome have expreffed in regard to its ufe in intermittents, and the interdiction which in fuch cafes others have pronounced againft it. We may explain alfo from the fame confiderations, why in the accounts that have been handed down to us of injurious effects from the ufe of cold drink in fevers, the greater part of the cafes have been intermittents. The inftances however that are recorded of the fatal effects of large draughts of cold liquids, have" more fre- quently occurred after fevere exercife and fatigue, than even in intermittent fever. The caufe of this is obvious— the heat preternaturally accumulated by exercife, is held with lefs tenacity than even the heat in intermittents. It is diffipated by the perfpirations that exercife occafions, and is fpeedily loft, when to profufe perfpiration is added a ftate of reft. It is then that a large draught of cold liquid is efpecially dangerous. But while the preter- natural heat is fuftained by continued exertion, cold li- quids may be taken in moderate quantities without pro- ducing any injurious effects. They may even, I appre- hend, be drunk copioufly without producing fuddenly the fatal effects already defcribed—but in copious * See Sennertus, lib. ii. cap. ix. p. 54.. Itaque Graeci-auctores jubent in ftatu, cum febris acuta, fitis, inquietudo, cordis & arteriarum pulfatio eft vehementiffima, aegerque avidiffime earn expetit, aquam frigidam co« piofe exhibere.— In intermittentibua febribus vero a^uae frigidae potus nunquam conrenit. 89 draughts, they are found oppreffive to the ftomach during exercife, and excite languor, naufea, and fome* times vomiting, as I have had occafion to obferve. In the narrative already mentioned of the march of Alex- ander's army through the defert country of the Sogdiani, it is related by the hiftorian, that a few of the foldiers, by the advice of the natives, had provided themfelves with water, of which under their burning thirft they drank immoderately. The confequence was, that they became heavy, feeble, an i unable to fupport their arms, and this flace of oppreffion was fucceeded by fevere vo- miting. Graves deinde avide haufto humore, non fuf- tinere arma ; non ingredi poterant -, et feliciores videban- tur, quos aqua defecerat, quam ipfi fine modo infufam vo- mitu cogerentur egerere. Q Curtius, lib. vii. cap. 5. The water thus wafted, or worfe than wafted, might have been ufed to advantage in wetting, from time to time, the garment next the fkin. Thus the oppreffion of its weight on the ftomach would have been prevented, and the furface of the body being kept cool by conftant evaporation, the heat of the fyftem would have been moderated, and the thirft alleviated.* If this account of the circumftances under which cold drink after fevere exercife proves injurious, be juft, the directions of Dr. Rufh to thofe who will drink in fuch circumftances, are founded on error. By abftracting a part of the preternatural heat of the body before drink- ing, the danger is not diminifhed, but greatly increafed. This enlightened phyfician will excufe thefe obfervations, drawn from me by a confideration of the importance of * Poftiiiions underftand the difference between giving their horfes cold water to drink, during exercife, aid after the exsrcife has ceafed. When in their power, they always water their horfes two or three miles before the end of"their journey. My friend, Mr. Charles Aiken, affures me, that during his tour on foot through Waies, in company with his brother, of which Mr. Aithui Aikin has given fo interefting and ufeful an account, tlK'_\ drank of the pure ftreams, as they defcended from the mountains, without referre, during the fervor of the day, taking care however never 10 reft after drinking. \1 9o the fubject, but accompanied by fentiments of fincere efteem and refpect. If the effects of cold water ufed internally under fe- vere exercife are not entirely analogous to the effects produced by its affufion on the fkin ;—the difference will be eafily underftood, by thofe who confider, that where a quantity of water is fwallowed, befides the in- fluence of the cold, the ftomach fuftains a load, from the weight and the bulk of the liquid, particularly op- preffive under the conftant action and agitation of the voluntary mufcles, from which the furface, moiftened with water, is entirely free; and on the other hand, that the evaporation from the furface, promoted by the im- mediate accefs of the external air, muft operate more directly in cooling the body, and particularly in coun- teracting the burning rays of the fun, than water taken into the ftomach. With thefe exceptions, the operation of cold liquids on the ftomach and on the furface of the body are analogous in the cafe of preternatural heat pro- duced by bodily exertion, as in all other cafes of pre- ternatural heat. As it is fafe to drink cold water in proportion as the heat from exercife is great and fteady, fo alfo it is fafe, according to this ratio, to pour it on the furface, or to immerfe the body in the cold bath. In the earlier ftages of exercife, before profufe perfpi- ration has difiipated the heat, and fatigue debilitated the living power, nothing is more fafe, according to my ex- perience, than the cold bath. This is fo true, that I have for fome years conftantly directed infirm perfons to ufe fuch a degree of exercife before immerfion, as may produce fome increafed action of the vafcular fyftem, with fome increafe of heat; and thus fecure a force of re-action under the fhock, which otherwife might not always take place. The popular opinion, that it is fafeft to go perfectly cool into the water, is founded on erroneous notions, and is fometimes productive of inju- rious confequences. Thus, perfons heated and begin- 9* rung to fweat, often think it neceffary to wait on the edge of the bath until they are perfectly cooled j and then, plunging into the water, feel a fudden chillinefs that is alarming and dangerous. In fuch cafes the injury is generally imputed to going into the water too warm, whereas in truth it arifes from going in too cold.* But though it be perfectly fafe to go into the cold bath in the earlier ftages of exercife, nothing is more dan- gerous than this practice after exercife has produced profufe fweating, and terminated in langour and fatigue, Becaufe, as has already been repeated more than once, in fuch circumftances, the heat is not only finking ra- pidly, but the fyftem parts more eafily with the portion that remains. This account of the operation of the cold bath, will explain fome circumftances very generally mentioned by writers on the effects of cold on the human body, and hitherto not properly accounted for. That the Roman youth, in the heat of their exercife in the Campus Mar- tius, frequently plunged into the Tyber, is a fact uni- verfally known; they found in this practice a high en- joyment, and they believed it conducive to health, and more efpecially to fleep. On the other hand, various relations may be cited of the injurious effects of an apparently fimilar practice; the moft remarkable of which is the cafe of Alexander the Great, when covered with duft and fweat, he threw himfelf into the Cydnus, and was feized with a difeafe, of which he nearly pei ifhed; one of the beft authenticated facts in ancient hiftory. * Dr. A. Munro Drummond, in his inaugural diffenation, *' De Fe- hribus Arcendis* the only fpecimen left of his admirable talents, fpeak- ing of the effects of the cold bath as a preventative againft the action of contagion, obferves, " Nee frigida protinus fugiendavel calida temperan- " da, quamvis cutis pallida aliquantifper fiat vel leviter aliquis inhorrue- " rit. Si exercitatio antecedat quae citra laffitudinem & fudoiem eft, haec " facile evitari poffe experiendo didici : et fere, fi nil aliud obftet, quo " ante quifque plus incalueret quam aquam intraverit, co calidioi emcr- 92 In the differtation De febribus arcendis, by Dr. A. Munro Drummond, thefe facls are brought together in the following words. Alexander, quondam diei fervidif- fimo tempore, liquorefluminis invitatus, vix dum in Cyd- num amnem d?fcenderat, cum gravi inde morbo implicitus eft. Romana juventus, foft quotidianas in Campo Mar- tio exercitationes, pulverefimul & fudore perfufa, Tyberi impune laffitudinem curfus natandi labore depofuit. Mali nimirum adfuetudine duramur in his ficut in cateris rebus omnibus. Ihes. Med. vol.m. p. 154- Doubtlefs the influence of habit has a confiderable fhare in regulating the effects of cold on the human body ; but the circum- ftances juft mentioned, feem capable of an explanation on other principles. On the Campus Martius, the exercifes of the Roman youth were carried on with all the vehemence of emula- tion. Swimming formed a part o thofe exercifes,* and generally terminated the foot-race. The youthful can- didates in this exercife directed their courfe towards the banks of the river, and plunged headlong into the ftream. Sometimes the contention did not terminate till they had fwam acrofs the river twice. Hence it will eafily be feen, that they were accuftomed to immerfe themfelves in water in the very fervor of their exertions, when the heat was preternaturally great; and not after the body was cooled by profufe perfpirations, or exhaufl- ed by long continued fatigue. In this fituation the prac- tice was fafe , without taking into confideration, that the perfons following it, were in the flower of life, fortified by early habits, and partly defended from the fhock of immerfion by the inunctions which feem to have been • See Horace, lib. i. ode 8. Where the poet, after queflioning Lydia why her lover neglects his accuftomed exercifes on the Campus Martius, among other pauiculars afks, Cur timet fla— On the firft of September, 1778, two ftudents of medicine at Edinburgh fet out on foot on a journey, a confiderable part of which lay along one of the rivers of Scotland. They ftartcd by fun-rife and proceeded with alacrity in the cool of the morning. At the end of eight miles, they breakfafted, refted for an hour, and then refumed their journey. The day grew warm as it ad- vanced, and after a march of eight miles more, they arrived heated, but not fatigued, on the banks of the river above-mentioned, about eleven in the forenoon.— Urged by the fervor of the day, and tempted by the beauty of the ftream, they ftripped inftantly, and threw themfelves into the river—The utmoft refrefhment fol- lowed, and when they retired to the neighbouring inn, this was fucceeded by a difpofition to fleep, which they indulged. In the afternoon they proceeded, and tra- * 1803. In an abridgment of this volume, faid to have been made by Mr. Vaughan, formerly member of the Biitifh Houfe of Commons, and publifhed in North America by Peter Eddes of Augufta, in the diftrictof Maine, the ingenious abridger, who frequently introduces valuable re- marks of hrs own, obferves on this paffage as follows. ** A number of " other feemingly contradictory, and yet authentic relations, receive here " alfo a fatisfaetory folution. Hence we may affure ourftlves, that if the " waters of the Miffiffippi never injure thofe who drink them in fummer, " whatever be their ftate as to perfpiration or fatigue ; it is not owing to " the quality of thefe waters, but to their ivarmth, in confequence of their " long expofure to the fun." There is no doubt of the juftice of this obfervation. The body of water which defcends the bed of the Miffiflippi, immenfe as it is, running for a thoufand miles and upwards, in a chan- nel, not perhaps at its upper end one hundred yards above the furface of the fea, and in the whole of its courfe expofed to the rays of the fun, muft acquire the temperature of the atmofphere; exhibiting however in the middle of its ftream, rather the average heat of the atmofphere for the three or four preceding days, than at the moment of obfervation. The fame may be laid of the waters of the Ganges, of the Nile and of othw vtreat -ivei-s 99 veiling fixteen miles further at a fingle ftretch, arrived at the inn where they were to fleep, a little after fun-fet, —The afternoon had been warm, and they fweated profufely; but the evening was temperate and rather cool. They had travelled for fome miles (lowly, and ar- rived at the end of their journey, ftiffened and wearied with their exercife. The refreshment which they had experienced in the morning from bathing, induced however one of them to repeat the experiment, and he went perfectly g>ol in- to the fame river, expecting to relax his limbs in the water, and afterwards to enjoy profound fleep. The confequences were very different. The Tweed, which was fo refrefhing in the morning, now felt extremely cold ; and he left the water haftily. No genial glow fucceeded, but a feverifh chill remained for fome time, with fmall frequent pulfe, and flying pains over the body. Warm liquids and friction brought on at length .confiderable heat, and towards morning perfpiration and fleep fol- lowed. Next day about noon they proceeded on foot, but the.traveller who had bathed was extremely feeble; and though they had to perform a journey of a fingle ftage only, as fome part of it was difficult and mountain- ous, he was obliged to take the affiftance of a carriage which overtook them on the road. It was feveral days before he recovered his ufual vigour. This relation will not I hope be deemed of the lefs authority, becaufe it is given by the perfon who fuffered by his impru- dence.* It is unneceffary to point out the application of thefe incidents to the doctrines already laid down. • Thofe who know the road from Edinburgh to Moffat, v, ill be at no loft to mark the different ftages of this adventure. I may here obferve, that illneffes fimilar to the above occur frequently, from the imprudence of the country people, (the Boltoners, as they are called), who make an annual vifit to the river below Liverpool, for tiie purpofe of bathing.—In fuch cafes, I have found the difeaie that follow- ed, was not inflammatory, as might be fuppoftd, tut :aiher a itv-.r c? debility, as in the inftance detailed. IOO It feems to be a general truth, that from whatever caufe the heat of the body is increafed, in proportion to this increafe, (provided no local difeafe has occurred), ,js the fafety with which cold may be applied. In the celebrated experiments of Dr. Fordyce, Sir Charles Blagden, and others, of which an account is given in the Tranfactions of the Royal Society, vol. lxv. p. 111, and 484, it is repeatedly mentioned, that thefe gentle- men paffed from a room heated to 200 deg. and upwards, into the cold air, with perfect fafety. " During the whole day," &ys Sir Charles Blagden, ts we paffed out of the ct heaetd room," (where the temperature of the air feems to have been 240 deg, and fometimes 260), '**' after every experiment, immediately into the cold air, '" without any precaution; after expofing our naked tc bodies to the heat, and fweating moft violently, we " inftantly went into a cold room, and ftaid there, even " fome minutes, before we began to drefs : yet no one " received the lpaft injury." Ibid. ^.494. The freedom from injury, and even from inconveni- ence, which thefe gentlemen experienced, depended on the increafed heat of the body, and the increafed action of the arterial fyftem.—Had they continued expofed naked to the cold air till the heat funk as low as its natural ftandard, and the heart and arteries fubfided into their ufual ftate of action, their fituation would have been very hazardous. In fimilar experiments, repeated at Liverpool, of which a detail is given by Dr. Dobfon, in the fame vo- lume of the Philofophical Tranfictions, p. 463, the gen- tlemen engaged in them paffed from the heated room into the cold air, with equal impunity. My friend Mr. Park affures me, that after remaining fome time in the ftove, where the heat was as high as 202 deg, he went into the external air without a great coat, or any other than his ufual clothing, during a hard froft, and perceived neither injury nor inconvenience. IOI In many manufactures, the perfons employed are ex- pofed to extraordinary degrees of heat, particularly in the manufacture of glafs. Such perfons, guided by na- ture, often endeavour to obtain relief, by expofing themfelves to degrees of cold, which on the commonly received opinions, would in their fituation appear ex- tremely dangerous. Thus at Glafgow, in the fpring of the year 1780, I learnt, that it was common for the workmen in the glafs manufactory, after enduring for fome time the confuming heat of their furnaces, to plunge into the Clyde; a practice which they found in no refpect injurious. A great variety of the phenomena refpecting the influ- ence of cold on the living body, receive an eafy expla- nation by attending to the principle already mentioned. Thus, after the heat of the body is increafed two or three degrees in the hot bath, it is not only fafe, but refrefh- ing, to plunge into the cold bath, as I have repeatedly experienced. A practice of this kind prevails, as is well known, in Ruffia, where it is common, after remaining fome time in the hot bath, to roll naked in the fnow, and return to the Warm bath as before. The Ruffian hot baths vary from 1064. deg. to 116 deg. of Fahrenheit/ and I md by experiment, that the actual heat of the living body is increafed in the hot bath, unlefs under particular circumftances afterwards to be explained, when the temperature is no higher than 100 deo-. We may therefore'fafely infer, that in making thefe fingular tranfitions, the heat of the Ruffian is in the firft in- ftance increafed beyond the natural ftandard ; and it is to this increafe that the fafety, as well as the agreeablenefs of the practice, is to be attributed; and from all thefe facts we may conclude, that, where the actual heat is confi- derably increafed and the body is not weakened by fa- * See Differt. phyfica experiment alls de colore Animalium, by J. A. Efaun, in the Nov. Comment. Academia Scientiarum Imperialis Petropo* litana, vol. xiii. The Abbe ChappeD'Auteroche fays the Ruffian baths are as high as 60 deg. of Reaumur, (160 deg. of Fahrenheit) Philofophiral Tranfaclions, vol. Ixv. /. 1125 but he fpeaks of vapour bath?.. 102 tigue, even the prefence of profufe fenfible perfpiration will not render expofure to a certain degree of cold dangerous. It is in this way that we muft account for the fafety of a practice, which prevailed at Rome under the firft of the emperors. After the overthrow of the republic, the Romans confoled themfelves for the lots of their freedom, by a more unbounded indulgence than ever in thofe fenfual gratifications which had led to their fall. Of thefe, the pleafures of the bath formed a diftinguifh- ed part; they fought every means of heightening and diverfifying them, and connected them with other epi- curean enjoyments. The mild and tepid immerfion of the Greeks no longer fijtisfied them; they heated their baths to the utmoft pitch of endurance; and, as they rofe, reeking from their furface, veffels full of cold water were dafhed over their naked bodies, as a high gratification in itfelf, and a means of ftimulating the fenfes to gratifications ftill higher. Such practices could not however be continued without injury. In the bagnios of Imperial Rome, the laft of the Romans, the followers of Zeno and Cato, wert melted down into fiaves; the powers of their minds became enfeebled, the vigour of their frames decayed, and they loft for ever the bold impreffions of freedom and of virtue.* * This fubject might lead to digreffions, which my limited plan does not admit. 1 fhall content myfelf with a few obfervations. Though private baths were in ufe in Rome from the earlielt periods of their hilto- ry, yet the fyftem of public hot baths did not, it is underftood, commence tiii the days of Auguftus. According to Dion, Maecenas introduced-it. —Agrippa followed his example—It was foon earned to an aftonifhing height, and the conftruction of baths were the p-.ople might be accommo- dated gratis, was an eftablifhed and a fuccefsful method of gaining their affections. The extraordinary expenfe and magnificence of thofe ftruc- tures are well known—the remains of the baths of Caracalla and Diocle- fian, teftt'y their former grandeur in our own days. According to Fa- bricius, there were 856 public baths at Rome, and fome of thefe were large enough to contain at once i8co perfons. The rage for hot bathing in Rome, under the firft Emperors, exceeded all bounds. In regard to the exact temperature of their baths, as the thermometer was not known to the ancients, we cannot fpeak precifely. We have 103 It was fuppofed by Dr. Cullen, who paid much at- tention to the operation of temperature on the living fyftem, that in all fudden changes, from a higher to a lower temperature, a fenfation of cold takes place, even though the loweft point of change be fuch as, when permanent, becomes oppreffive by its heat. Thus, that a change of the external air from 90 deg. to 85 de- grees, is accompanied by a fenfation of cold, though this fpeedily goes off, and is fucceeded by a fenfation of heat, if the temperature of 85 deg. be continued.* This obfervation ought, I think, to be reftricted to de- grees of heat inferior to that of the human body, for in does not feem true when applied to fuperior degrees of heat. If, for inftance, a perfon is immerfed in a bath heated to 104 degrees, and a quantity of cold water be fpeedily admitted, fo as to lower it to 98 degrees, a fenfation of a very agreeable nature takes place, not however to be denominated cold—Where the actual heat of the body has been raifed, and the circulation accelerated, a much greater reduction of the tempera- however the authority of Seneca and Plutarch for faying, that the bath oi, the Greeks was of a moderate temperature : and, as Alexander found re- freshment in the bath, in the burning fever of which he died, it probablv did not exceed 93 deg. or at moft 96 deg. of Fahrenheit. But at Rome, in the days of Seneca, the hotteft baths were moft in eftimation, and thofe of Nero leem to have exceeded all others in heat—We may inftr this from one of the beft of Martial's epigrams. Si temperari balneum cupis fermens, Faufiine, quod f the breath, and in a confiderable falivation. io8 Had poor Gardner been a man of any rank, or indeed had he been furrounded by his family, it is moft proba- ble that we muft now have abandoned him to his fate. But our proceedings being obflructed neither by the prejudices of ignorance, nor the weaknefs of affection, another, and a laft effort for his life was refolved on. Having heard that the cold bath had been employed with fuccefs in tetanus in the Weft Indies, particularly by Dr. Wright of Jamaica, and Mr. Cochrane of Ne- vis, and this practice correfponding with certain fpecu- lations of my own, I had recouife to it on this occalion with fome little confidence. With the confent of his officers, Gardner was carried to the public falt-water baths of this town, then of the temperature of 36 deg. Fahrenheit, and thrown headlong into it. The good effects were inftantaneous. As he rofe from the firft plunge, and lay ftrugglin^ on the furface of the water, fupported by two of his fcllow-foldiers, we obferved that he ftretched out his left leg, which had been for fome time retracted to the ham. But his head did not imme- diately recover the fame freedom of motion, and there- fore he was plunged down and raifed to the furface fuc- ceffively for upwards of a minute longer, the mufcles of the neck relaxing more and more after every plunge. When taken our, we felt fome alarm : a general tremor was the only indication of lite, the pulfe and the refpi- ration being nearly, if not entire fufpended. Warm blankets however had been prepared, and general fric- tion was diligently employed. The refpiration and pulfe became regular, the vital heat returned, the mufcles continued free of conftriction, and the patient fell into a quiet and profound fleep. In this he continued upwards of two hours, and when he awoke, to the aftonifhment of every one, he got up and walked acrofs the room, complaining of nothing but hunger and debility. The convulfive hiccup indeed returned, but in a flight de- gree, and gave way to the ufe of the cold bath ; which he continued daily a fortnight longer ; and in lefs than a 109 month we had the fatisfaction of feeing our patient un- der arms, able for the fervice of his country. That the opium, though it failed in effecting a cure, had confiderable influence in mitigating the difeafe, and prolonging life, is, I think, apparent. That the mercury had little effect, is clear from the fecond convulfions coming on foon after the falivation appeared. The fuccefs of the cold bath in circumftances fo ap- parently defperate was not leffened by bad effects of any kind. Though the patient was in a falivation when thiown into it, yet this was not flopped fuddenly; it lefft ned indeed immediately, and foon difappeared, but without any of thofe bad confequences fo well defcribed by Sir John Sylvefter and Dr. Dobfon. Subfequent ex- perience has taught me to attribute fome part of the fud- dennefsofthe benefit obtained in this inftance, to a cir- cumftance that diftreffed me much at the moment. The very inftant that we were about to immerge poor Gardner, he was feized with a general convulfion. We hefitated— but kept our purpofe, and happily plunged him into the water with the convulfion upon him. I am alfo incli- ned to think, that our fuccefs is in part to be afcribed to the powerful, general, and fudden application of the re- medy, and in this view of the fubject, immerfion is in certain circumftances perhaps preferable to affufion. i. Soon after this I was fent for by a poor woman, who, in confequence of a difficult labour, and as fhe imagined, of local injury in fome part of the uterus, was feized with the fpafmus cynicus, and locked jaw. She was immediately taken to the cold bath, and thrown into it in the fame manner as the former patient, and with fimilar good effects. The fpafms difappeared, and though they afterwards returned in a flight degree, they gave way entirely to a fecond immerfion. no In the firft of thefe cafes I was affifted by Mr. Walk. er, furgeon's mate of the Staffordfhire militia; and in the fecond cafe the effects of the cold bath were wit- neffed by him and my friend Mr. Park. So far of the idiopathic tetanus; my experience of the effects of the cold bath in the difeafe originating in wounds, is neither fo fatisfactory nor fo complete. 3. The firft cafe that occurred to me was that of a matter of a veffel returning from fea in the year 1784. The injury had been received on the leg, but the wound had little inflammation on it, though the patient was fo far advanced in the difeafe, as to go off in a general convulfion, before any remedy could be tried. 4. The fecond cafe feemed rather an inftance of lock- ed jaw, properly fo called, than of tetanus. The injury having been received on the jaw itfelf, the affection was confined to the mufcles Of that part, and thedifeafe feemed to be the trifmus inflammatorius of Sauvages. It gra- dually yielded to bleeding, and the topical application of warm vapour, the cold bath producing no good effect. 5. In the third cafe, we contented ourfelves with pouring cold water in fucceffive buckets on the patient's head, partly becaufe this was the moft convenient me- thod, and partly becaufe it is that employed by Dr. Wright, whofe paper on thefubjed, in the fixth volume of the Medical Obfervations and Inquiries, had by this time appeared. While we were bufy in this way, and flattering ourfelves with fome appearance of fuccefs, the unhappy patient fuddenly threw himfelf on his back, and a quantity of water entered his mftuth. The effects were highly diftreffing. The mufcles of deglutition were unable to carry down or to expel the fluid, and fuch convulfions took place, as led us to expect inftant death. He recovered, however, fo far as to regain his III former fituation, but the effects of his fufferings on the bye-ftanders prevented our continuing this practice, and he was carried off a few hours after. 6. A fourth inftance of this difeafe I faw about two years and a half ago. There was no room for new prac- tice, for the patient was too far advanced. He had been treated with opium and mercury as ufual, and as ufual died. Thefe cafes afforded little inference either in favour of or againft the ufe of the cold bath in tetanus arifing from wounds, but they are dated fhortly, that the ac- count of my experience in this difeale may be fair and complete. It is worthy of remark, that the ufe of the cold bath in tetanus, is a practice of very ancient date. Dr. Wright, whole precifion and candour are exemplary, mentions, that he received the firft hint of it from Dr. Lind of Haflar. Hippocrates, however, was acquaint- ed with it, as appears by Aphor. 21. lib. v. It is alfo noticed by Avicenna, lib. iii. cap. 7. and in the collec- tion of Schenkius, p. 120, an account of the fuccefs of this practice in two cafes of tetanus is quoted from Ja- fon, cap. 21, De morbis cerebri ex Valefeo. Hippocrates indeed, and Avicenna, reftrict the ufe of this remedy to the young and corpulent, and to the fummer feafon. They alfo confine it to cafes in which the difeafe has not originated in local injury; for it appears by another of his aphorifms, that the father of phyfic thought con- vulfions fupervening to a wound always fatal.* The ex- perience of Dr. Wright encourages us to extend this re- medy to tetanus originating in wounds, but if it fhould fail, we are ftill not to defpair, as the following cafe will teftify. • Hippoc. Aph, lib, iv. feci. v. aph. a. I 12 7. In July 1787, alabouring man was brought into our Infirmary with a wound in his hand. He was under Mr. Park's care, and the fore was nearly healed, when an alarming rigidity appeared in the motion of the jaw. Opium and mercury were immediately prefcnbed, with which were conjoined, firft the cold, and afterwards the warm bath. Mr. Park, however, finding the difeafe to proceed with the moft unfavourable omens, called a con- fultation, at which, in the abfence of the reft of our col- leagues, we agreed to make a trial of bark and wine, on the authority of Dr. Rufh of Philadelphia, whofe paper on this fubject, in the fecond volume of the American Philofophical Tranfactions, had juft appeared. We had, however, little or no hope, for the difeafe was far advanced, and its progrefs had been very rapid. At this time the jaw was not only rigidly contracted, but the fpafms had extended to the neck and back, the pain under the enfiform cartilage was moft acute, and twice or thrice in every hour he was feized with general con- vulfions, each of which lafted about half a minute. The patient was, however, a man of a vigorous mind, and in his perfect fenfes; and his danger was not con- cealed from him. Death, he was told, muft be the ine- vitable confequence, unlefs he fwallowed wine in large quantily, but this we verily believed would fave him. At firft bark was infufed in the wine, but he could not iwallow the mixture, and therefore we trufted to wine ( alone. It was wonderful to fee the exertions which this poor fellow made. If the liquid was offered to him at an improper time, the effort of deglutition brought on a general convulfion; nay a general convulfion was the confequence of advancing it at fuch a time towards his head. But watching the remiffion of the fpafms, he was able to fwallow a table fpoonful or more at once, he him- felf giving the fignal when the wine fhould be adminif- tered.* In this way, through the opening made by the * This circumftance fuggefted to me the fimilarity between this cafe ind hydrophobia. I noticed it to my refpe&ed friend Dr. Percival, who "3 lapping of the tipper jaw over the under one, he drew up and fwallowed a quart of port wine in the couife of two hours; at the end of which time he thought him- felf refrefhed, and was encouraged to proceed. At the end of twenty-four hours he had finifhed his third bot- tle, and at this time it was evident that the down-hill progrefs of the difeafe was checked. Though the pain under the enfiform cartilage (the moft excruciating of all the fymptoms of tetanus) was little abated, yet he felt himfelf more able to bear it; and the general convul- fions were certainly lefs frequent and lefs fevere. We continued our plan with patience and vigour, but for a long time life and death feemed to hang in equal fcales. On the fifteenth day of this courfe he was affected with a flight naufea and vomiting, which foon went off, and thenceforward recovery feemed more apparent. It was not however till he had been forty-two days under this treatment that his fafety could be ascertained, and during this time he fwallowed a hundred and ten bottles of Port Wine. In this cafe bark was adminiftered along with the wine towards the latter period of the complaint; and during the whole of it, gruel or milk in the quantity of a quart a day, or upwards, was given by way of nourifhment. The milk, however, he preferred, as agreeing better with the wine, and tending, as he conceived, to allay a burning fenfation at his ftomach, the effect of an acid ferment there. Though the wine was given in fuch quantity, yet it never produced any fymptoms of ebriety—it foothed the irritation of his nerves, and comforted his mind, and, without increafing the^ffcquency of his pulfe, it aug- mented his ftrengtb. has mentioned it in his eflay on that difeafe. Vide Percival's EfTays, vol. ii. p. 366, 4to edition. I differ however from this experienced phyfician in his fuppofition that the two difeafes are the fame, or of the fame origin, '5 U4 £very night he took from fixty to a hundred and twenty drops of the tincture of opium, and, with the wine, this fmall dofe feemed to have a more compofing effect than thrice the quantity taken before he be- gan it. To allay the pain under the enfiform cartilage, cloths, dipped in asther, were applied externally with good ef- fects. As I flood by him one day, prefTing the doffils with my open hand to the fcrobiculus cordis, he ex- preffed himfelf relieved by the force which I applied. The fame relief feemed to follow from a gentle and uni- form prefiure on the parts fuffering from fpafm. In confequence of this, rollers were applied round each thigh, where fpafmodic twitchings had been very dif- treffing, and afterwards, at his own requeft, a general preffure of the fame kind Was applied to the back and abdomen. Thefe bandages he would not fuffer to be removed, but we poured aether on them occafionally, over the parts molt affected by fpafm, guarding in the ufual way againft the cold produced by too fpeedy an evaporation. At length our patient recovered. He is now (1790) a watchman, and calls on me occafionally. He com- plains of a ftiffnefs at times in the mufcles of his back, and though naturally a ftrong and healthy looking man, his features retain the indelible impreffion of his difeafe. His eyes appear hollow, his face fharp and pale, his cheeks and lips are fkinny, and the maffeter mufcles hard and fhrivelled. I have lately had an account of a cafe of this kind which occurred in a failor on the coaft of Guinea, who recovered under the care of Mr. Robfon, an ingeni- ous furgeon in the African trade, from a ftate apparent- ly defperate, by a very liberal ufe of bark and ardent fpirits. J15 i'o conclude this part of my fubject, I have known two inftances of this difeafe in horfes, both originating in wounds ; the firft of thefe was treated in the method firft defcribed. The cold bath was ufed repeatedly, and large dofes of opium employed in the form of clyfters; but the difeafe terminated fatally. The fecond of thefe occurred in a horfe of Dr. Camplin's about a twelve- month ago in his journey to Bath. The doctor informs me, that he gave him wine and opium, mixing fixty drops of laudanum with every pint of wine, and by this practice he had the pleafure of recovering him, though not till he had drunk as much wine as he was worth. Brandy or gin may perhaps be as fuccefsful in fuch cafes. It may be fuppofed, that thefe inftances of fuccefs in the ufe of the cold bath in tetanus, would lead me to employ it in other convulfive diforders. This has ac- cordingly been the cafe. Of the ufe of the cold bath in fuch diforders I can fpeak with fome confidence, as my experience of it is now of feveral year's duration. In the convulfions of children, I have found the cold bath a moft ufeful remedy, whether the diforder origi- nated in worms or other caufes. I have feldom known it to fail in flopping the paroxyfms, at leaft for fome time, and thereby giving an opportunity of employing the means fitted to remove the particular irritation. I muft however obferve, that in early infancy I have ufed it with caution, and generally by affufion, tempering the water when the weather was cold. I have in gene- ral made the application of cold in this way fudden and tranfient, have employed means to fecure re-action, and have avoided the remedy entirely in all cafes where the vital energy feemed much exhaufted. With thefe pre- cautions I have feen great fuccefs attend this remedy in a variety of inftances. Minutes of* feveral of thefe I have preferved, but I mean to give one only in detail n6 John Slater, aged eight years, came under my care in the month of January, 1782. About two years be- fore, while at play, he was feized fuddenly with a con- vulfion which continued for half an hour, and had re- turned ever fince at fhort intervals. Various means had been employed for his relief, but without fuccefs; the fits wi re become more and more frequent, a hemiplegia had fu^ervened, and the intellect was apparently loft. For twenty four hours he had lain in a ftate of infenfibility, motionlefs on the left fide, and the mufcles of the other fide only agitated by convulfive tremors. We put him immediately into a tub of cold water, which mftantly flopped the paroxyfm, and threw him into a deep fleep, out of which he awaked after two hours with a fhriek, and fell into convulfions as before. The cold bath was repeated, and afterwards continued daily, prefent relief being always obtained by it. The interval was em- ployed in adminiftering the tin powder, which was worked off with calomel, but no worms were obferved to be di charged. After feveral days the convulfions returning, though with a confiderable abatement, I be- came diiTatisfied with the mode in which the bathing had been performed, the fize of the tub employed ne- ver having admitted of fudden immerfion. On this account we had the child conveyed to the public bath, into which he was thrown headlong, his father being ftripped in the water to receive him. The temperature of the bath was 43 deg. of Fahrenheit. He was re- peatedly plunged down and taken up for half a minute; was taken out of the water free of convulfion, fell im- mediately into a profound fleep, and awaked clear of complaint. In thefe lefpe&s this cafe relembles that of Gardner, firft defcribed It relembles it alfo in this refpedt, that convulfion had taken place at the moment of immerfion. The paralytic weaknefs of the fide re- mained however for fome time, but by the continued ufe of the bath, it was at length entirely removed; and the powers of the mind, which had betn totally fuf- ii7 pended, gradually returning, at the end of fix months were perfectly reftored. He continued well upwards of twenty months, was healthy and vigorous in body, and in the acquirement of knowledge remarkably acute. But on the 30th of December, 1783, his mother having ftruck him and frightened him much, he was feized in the night during fleep with general convulfion, in which he continued feveral hours without intermiffion. Being again called to him, I employed the fame remedy, but at the time of immerfion the convulfion was not on him. Sleep and refrefhment followed as before, but the paroxyfm returned in the evening, though in a flighter degree. However, by perfeverance in the daily ufe of the bath, and throwing him twice into the water with the convul- fions upon him, in fix dzys his health was reftored. I lament over the fate of this amiable boy. He con- tinued from this time three years and a half in perfect health; grew ftrong and tall, and fhewed great affection of temper and fenfibility of mind. But being violently agitated with fear and grief, he fell again into convul- fions in the month of July, 1787. I was fent for as ufual, but was abfent from town at a confiderable dif- tance. Having on former occafions launched him my- felf into the bath, his mother, a fuperfticious woman in a low walk of life, would not permit this remedy to be ufed till my return. He lay for thirty hours con- vulfed and fenfelefs, and the firft intelligence I had of his illnefs, was accompanied by the account of his death. This cafe differs materially from the convulfions of early infancy. 1 give it therefore not as an inftance of thefe, but as a fpecimen of a difeafe affecting children from four to twelve years of age, and which, though not very uncommon, as far as I can judge, has not yet found its place in any fyftematic work that I know of n8 Thenofology of convulfive difeafes is indeed very im- perfect, and the terms we employ in defcribing them are by no means precife. Thofe who have feen tetanus and the difeafe laft mentioned, will know, that what is called convulfion in both inftances, is in the one cafe and the other a very different affection. The convul- fion of tetanus is a fudden and violent contraction of all the voluntary mufcles, throwing the frame into ftrong contortions, but lafting only a minute at moft, and fel- dom fo long. The patient, where the cafe terminates fatally, probably dies at laft from fpafmodic affection extending to the heart, or fometimes perhaps, from the fufpenfion of refpiration. The convulfion in the other cafe, though it begins with violence, foon fubfides, leaving the body in a ftate approaching to coma: and though the feparate fibres of many of the mufcles keep in eonftant vibration, and the turbulence of general convulfion returns occafionally, yet in the intervals the refpiration is natural, and the pulfe little difturbed ; vo- luntary motion and confeioufnefs, are, however, com- pletely fufpended.* If this ftate continues long, the violent commotions return more frequently, the breath- ing becomes laborious, the ftrength is at length exhauft- ed, and the patient dies with the fymptoms of apoplexy. I conclude thefe details with a few general remarks. i. It appears to me that the efficacy of the cold bath in convulfive diforders is much promoted by being em- ployed during the prefence of convulfion. How 1 came to be led into this opinion may be feen in the cafe of Gardner. Much experience is required to eftablifh this as a general truth, and I give it as an opinion only. As madnefs is, I think, beft combated in the height of the phrenzy, fo I believe convulfive difeafes are moft capa- * This fpecies of convulfion has been denominated clonic, in oppofition to tonic, but with .little propriety. All convulfions may be laid to be : 'unic. n9 ble of remedy in the agitation of convulfion. I feem to have a glimpfe of a general principle in nature that connects thefe facts fo apparently different; but the ground is not yet firm enough for the foundation of a theory. 2. It may however feem to ftrengthen the above re- mark, that in the fpafmodic difeafes, which rife not to general convulfion, the cold bath feems to be .of inferi- or efficacy. In Chorea Sancti Viti I have tried it fre- quently, but never found it of any fervice. This is one of the few difeafes in which electricity is of decided ad- vantage. 3. In the hyfteric paroxyfm, the cold bath,* or indeed the plentiful affufion of cold water, is an infallible re- medy. Thofe who fuppofe that the terror it occafions ought, in this cafe, to prevent our having reeourfe to it, are, in my opinion miftaken. Though the hyfteric pa- roxyfm be the offspring of pafiion, it is never occafion- ed, I will venture to affert, by the paffion of fear. A fenfe of danger will always, I believe, prevent it; or indeed a powerful dread of any kind. I have known a tub of cold water kept in readinefs, with the certainty of being plunged into it on the recurrence of the paroxyfm, cure this difeafe, without the remedy being ever actu- ally tried. I know the hyfteric paroxyfm often takes place when danger is over, but that is another cafe. 4. I have tried the cold bath in the epileptic pa- roxyfm, but my experience of its effects is as yet, (1790), too recent and too imperfect to be detailed. I am not fo fanguine as to expect that experience will accumulate rapidly on this fubject. Many there are who will think my practice too hazardous to be copied, even after this account of its fuccefs. This relates efpe- cially to the ufe of the cold bath in convulfive difor- ders in private practice; but in hofpital practice, and in the practice of the fleet and army, the fame objec- 120 tions do not prefent themfelves j and in thefe de- partments of the profeflion it may be expected that its effects will be afcertained. Dr. Girdleftone, in his account of the difeafes among the troops in India, mentions, that hot Madeira wine is given with fuccefs in the tetanus which occurs in that climate; but he tells us, though not from his own ex- perience, that the cold bath has been very unfuccefsful. To what circumftance it may be owing, that a remedy which has been fo efficacious in the Weft Indies, fhould have failed in the Eafl, does not appear; though, if the circumftances under which it was employed were fully related, the difficulty might perhaps be explained. It may, however, be obferved, that in the fultry cli- mate of India, where the human frame is greatly re- laxed, it will not be fafe to ufe the cold bath with the fame freedom as in more northern regions. And it will undoubtedly be more fafe, in any future trials of this remedy in that country, to ufe the method of affufion employed by Dr. Wright, and fo fuccefsful in his prac- tice in a fimilar climate, inftead of immerfion, which it appears was employed in the cafes mentioned by Dr. Girdleftone. 1798. Since the above was written, I have feen three different cafes of tetanus arifing from wounds, in which the affufion of cold water was employed alone, and in all of thefe the difeafe terminated fatally. I have feen a fourth cafe in which the affufion of cold water was con- joined with the liberal ufe of wine and opium, where the patient recovered. And I have feen two other cafes in which the cure was trufted to wine and opium alone, in one of which the iffue was fortunate, in the other unfortunate. It is however proper to obferve, that in the three firft cafes, the difeafe was far advanced, having refifted other powerful remedies before the patients fell under my 121 care; and as the power of deglutition was nearly loft, the affufion of cold water was employed under defperate circumftances, as a dernier reffort. It was befides im- poflible to ufe this remedy to any extent, for the powers of life were too much exhaufted to fuftain the continued application, or the frequent repetition, of fo violent a ftimulus.—There is alfo in the advanced ftage of teta- nus, an objection to the ufe of a remedy that requires much change of pofture^ In fuch cafes, every exertion of the will on the voluntary mufcles has a tendency to induce a general convulfion.—From a confideration of all thefe circumftances, and from more extenfive expe- rience, I fhould now be difinclined to the ufe of the cold bath in any of its forms, in the fymptomatic teta- nus, unlefs in the earlier ftages of the difeafe, when the vigour is lefs impaired, and the convulfive actions lefs firmly catenated. The practice, firft introduced by Dr. Rufh, of giving wine in large quantities in tetanus, of which a fuccefs- ful cafe is detailed in this chapter, feems to me to be fully confirmed, as a moft important part of the treat- ment of this very dangerous difeafe. The wine ought however to be combined with considerably larger dofes of opium, according to my later experience, than in the cafe already referred to. I have now employed the cold bath in other convul- five difeafes for fourteen years, and on the whole, it has been attended with confiderable fuccefs.—One conclu- fion, of rather a Angular nature, was drawn from the cafes formerly given, which my fubfequent experience has uniformly corroborated :—" That the efficacy of the cold bath in convulfive diforders, is much promoted by its being employed during the prefence of convulfion;" or, as I would now exprefs it, that the benefit derived from the cold bath in convulfive difeafes, depends on its being ufed in the paroxyfm of convulfion •, that its efficacy confifts in refolving or abating the paroxyfm ■, and that 16 122 when this effecl is produced, the return of the paroxyfm is greatly retarded, if not entirely prevented. To this finerular fact, for which 1 am unable to account, I invite ^attention of phyfiologifts: it may throw fome light on the laws of affociation; a fubject of fuch vaft import tance in phyfiology, and which hitherto has been fo little underftood. The following cafe, taken from the records of our Infirmary practice, is in many refpects curious, and will ferve to corroborate the pofition juft laid down. John Weftmore, aged 22, was admitted into the In- firmary on the 1 ith of October 1792. In confequence of a fright, he had been feized with fits two months before, which now recurred feveral times every day, of various duration, from two minutes to an hour. Du- ring thefe his confeioufnefs was wholly aboliftied. Thefe fits occurred without warning, and were peculiar in their appearance. At firft the mufcles of one fide were ftrongly retracted, then thofe of the other, alternately; and then the mufcles of both fides acting together, the whole trunk of the body was drawn upwards to the head; this action, refembling very exactly that of the victim of the law, fufpended from the gallows in the agonies of death. His faculties of mind did not feem as yet impaired, nor the animal functions much difturb- ed. No medicines were ordered for this patient, but a bucket-full of cold water was directed to be thrown over him, the inftant of the acceffion of the fit. Some cir- cumftances prevented this being done for a few days, during which he went into the cold bath daily when the fits were off him, and with feeming advantage; the number of paroxyfms being reduced from eight or ten in the twenty-four hours, to two or three. At length he was thrown into the cold bath on the inftant of the accefiion of one of his fits, which was fpeedily termi- nated, and from this time forth he had no return for fourteen days, when he was difcharged as cured. Weft- more continued free of complaint till the beginning of February following, when his fits returned. He was I23 have been very minute in detailing the circumftances under which this experiment was made; fome of the parti* culars, which, at the time, 1 thought of little confequence, I found afterwards of importance. The experiment itfelf I determined to repeat as exactly as poflible. EXPERIMENT II. On the next day, at the fame hour, the fame perfon was again immerfed, as before. His pulfe previoufly was 85, his heat 100 deg. He had been put to bed an hour before, to fave the time fpent in undrefiing. The heat of the water and of the atmofphere 44 deg. The wind north-eaft, and ftrong. On this occafion, as before, there was a rapid fall of the mercury; the following table will fave words: Ther. min. after immerf. 894. 9°T 921 9*i 95 9Sl 9Si 9 mm. 1© — 11 — 12 — 13 — 14 — after immerf. Ther. 95r 944 95 95 954 95 At the end of fifteen minutes he was taken out, and ftood three m nutes, naked, expofed to the north-eaft wind, at the end of which time the mercury had funk to 88 deg. A draught of ale was given him, and he was put H7 into a warm bed; in three minutes afterwards the mercury rofe to 93 deg. An hour after his heat was 95 deg. The effects produced by this alternate expofure to water and air of the fame temperature, gave a new direction to my thoughts, and determined me to inquire again into this fingular phenomenon. The moft obvious method would have been to have prolonged the procefs of alternarion, and replunged the perfon cooled by the external air into the bath ; but this was running too great a 1 ifque, unlefs fome more fudden and certain method could be found o^reftoring the heat that mighc be loft. It was prudent, therefore, to proceed more cautioufly. In the next experiment I refolved to try the methods of heating, as well as of cooling the body. EXPERIMENT III. On the following day, at the fame hour, the fame per- fon was again immerfed in the falt-water bath. His heat previoufly was 98 deg. his pulfe 100. The temperature of the air and the atmofphert, as before, 44 deg. The mercury funk rapidly to 90 deg. Ther. minutes a fter 88° 88 88± 901 92 92 94 94 10 11 12 l3 14 '5 16 minutes after Ther. 94i° 94t 95 96 96 96 96 He was now taken out, and ftood in the wind three minutes, fhivering violently. This circumftance rendered it difficult to afcertain exactly the fall of the mercury, which was, however, confiderable. When he was ex- amined in the room in which he undreffed, it ftood at 90 deg. He was now plunged into a frefh water warm bath, heated to 974 deg. What is very furprifing, the mercury fell two degrees.—The following tabic will fhew the pro- grefs or the return of his heat. i4& Ther. 1 min. after immerf. in warm bath, mercury, 88° 1 minutes, ... 92 3------ ... 92 4------ ... 94 5 minutes after, 6------ . . 7------. . 8------ . . Thir. 94° 96 96 96 96 If the rife of heat in the cold bath at 44 deg. and the warm bath at 97 ^ deg. be compared, the firft will be found more flow; but that after being fixteen minutes in the one and in the other, the heat was the fame in both cafes, when taken at the mouth. It muft, however, be acknowledged, that in the cold bath, the extremities were chilled and cold, while in the hot bath, the heat was equally diffufed.— When Edwards got out of the hot bath, he put on his clothes, and was remarkably alert and cheerful the whole evening. Encouraged by the fafety of thefe experiments, I refolved to increafe the time of immerfion in the cold bath, and to inquire more generally into its effects on the fenfations, as well as heat. EXPERIMENT IV. At the fame hour of another day, the fame perfon was again immerfed as before, his heat being previoufly 97!^ deg. and that of the water 42 deg. W^ind north-eaft, and brifk. Ther. 1 minute after, heat 2 minutes 3------- 4------- 5------- 6------- 7------- 11 Ther. 90° 92 92 92^ 92 921 94 94 12 minutes "J------ 14------ 15 to 24, 25------ 26, 27 28 ------ 29, 30 94tc 94v 94 94, 94 there are 9, 10, It will be obferved, that in the above table blanks left in the report. At fuch times the thermometer' was taken out of Edwards's mouth, to admit of his anfwer- ing the queftions put to him. He faid, that on plunging into the water, he felt an extreme cold, which he could not 149 but think was partly owing to his being expofed, naked, to the wind before; that this cold dirninilhed, and in a little while he felt comfortable, but that after a while the \ fenfe of coldnefs returned, though lefs than at firft ; dimi- nifhing again, but in a lefs degree. At length his fenfa- lations became pretty fixed. In this ftate, when the water ;; was at reft, he fhould not even have known, by his feelings from the upper part of his cheft to the pubes, that he was '■' in the water at all. His feet and legs were very cold ; fo i» were his hands and arms ; and fo alio the penis and fcro- ?.: turn. He mentioned, likewife, that he felt a cold circle .:; round the upper part of his body, though not conftantly. i. On examining into this, I found it was greateft at firft, . and that it extended over the fpace which, from the undu- nlations left in the bath by the plunge of immerfion, was [•alternately above and under the furface of the water: when ;lx the bath fettled, it was little felt; but by agitating the fluid, 5-1 could reproduce it at any time when the cold in the ex- tremities was not fo great as to prevent its being felt. This curious particular ferves to explain a circumftance much dwelt on by Mr. Amyat, in giving an account of his fuf- ^ferings on the wreck; that what he felt moft feverely was : the cramps in the mufcles of his hips and fides, parts ,,(,which, from his fituation on the wreck, already defcribed, muft have been alternately under and above the furge. Here I muft obferve, that the fea did not break over them. The wind moderated, as well as the waves, and for the laft fifteen hours, they were not at any time overwhelmed, or at leaft Mr. Amyat himfelf was not. The cold never abated. Being all lafhed to the wreck, they never chan- ged their pofitions; the bodies of thofe who died occupied the fpace where they were originally placed. Mr. Amyat, (.therefore, during the whole time fat nearly up to thejmid- die in water, but fubject to the variations occalioned by the motion of the fea. t % To return—When expofed naked to the wind, the mer- (jcury, in thisjcafe, funk as ufual five or fix degrees, and :his fhiverings were great. Defirous of reltoring his heat "as fpeedily as poffible, we incautioufly heated the hot bath ISO to 104 deg: but after being half a minute in it, he fcream- ed out with pain, efpecially in his extremities, and about his fcrotum. When taken out, his fhiverings almoft amount- ed to convulfion. The bath was lowered to 88 deg. and he was replaced in it, and its temperature progreflively, but pretty rapidly increafed to 100 deg. He continued, however, to fhiver much, his heat remaining about 90 deg; but a bladder, with very hot water, being introdu- ced under the furface of the bath, and applied clofe to his ftomach, the good effects were inftantaneous, his fhiver- ings ceafed, and this heat mounted rapidly to 98 deg. All thefe experiments having been made on one perfon, I determined to repeat this laft on another. EXPERIMENT V. R. Sutton, aged 19, of a pale complexion, and a fee- bier frame, was immerfed in the bath, under the circum- ftances of the preceding experiment. His heat was previ- oufly 964. degrees. 4- a min. after, heat 1 minute 1 minutes . 3 ------ 4----- 5----- 6----- 7 to 10 11 ---- 12 to 15 16---- '7 -— Ther. 9*° 90 884 89 90 92 924 92 92 924 93 21 — 18 minutes 19------- 20, 22 ■ 23- 24. 25- 26. 27. 28 • 29. 3o- Ther, 93t 94 9^1 94 9*J 94 94 924 94 94 Though this perfon feemed to bear the cold bath well, having loft in thirty minutes only 24 degrees of heat, yet when expofed afterwards to the wind, he fhivered violent* ly, and loft his heat very faft. He was put into a warm bath, heated to 96 deg. but recovered his heat very flowtyj as the following table will fhew. *5* i minute after, heat 88° 2 minutes. 3------ 4 — 5 — 6 — 7 — 8,9 io — 11 — 12 — >3 — 14 — »5 16 90 9°t 90 90 90 90 9°T 92 92 94 93 93 94 96 great fhivering. here the bath was heated to 1000. fhivcrings ftill. ditto. ditto. ditto. bath heated to 1040. ..... heated to 1080. Shiverings. a bladder with very hot water applied to the ftomach very comfortable. EXPERIMENT VI. Richard Edwards, the original fubject of experiment, was again immerfed in the cold bath, of the temperature of 40 deg. and remained in it three quarters of an hour. His heat previoufly was 97 deg. his pulfe 90 in the minute. The mercury fell at firft to 92 deg. was ftationary for a few minutes, and then mounted, though as ufual, with no regularity. In twenty-two minutes it ftood at 96 deg; it then began to decline, and in twenty-three minutes more, had funk to 94 deg. Being expofed as ufual to the wind, the mercury funk as ufual, and he fhivered violently. In the warm bath at 96 deg. his fhiverings continued feveral minutes, his heat remaining at 90 deg. and 91 deg. In feven minutes the mercury began to rife faft, and five mi- nutes after it was at 96 degrees. EXPERIMENT VII. at; lf! The effects of forty-five minutes immerfion in the cold , falt-water bath, at 40 degrees, were propofed to be tried 5 on Richard Sutton. He was much under the impreffions f[of fear, and his heat previoufly raifed the mercury only to 94 deg. The mercury funk, as ufual, on his immerfion, but to an unufual degree. It did not flop on its fall till it ^S2 got to 83 deg. which perhaps might in part be accounted for by the extraordinary chattering of his teeth, admitting fome contact of the air. It then mounted in the ufual ir- regular way, and at the'end of thirteen minutes had got to 92 degrees. Here it ftood for nineteen minutes longer, with little variation; at the end of this time it began to fall rapidly, though irregularly, and in three minutes was down at 85 deg. He had now been thirty-five minutes in the water, and I did not think it fafe to detain him longer; we therefore hurried him into a warm bath, heated to ^ deg. where he fhivered much.—The bath was heated gra- dually to 109 deg, and in this heat he recovered his pro- per temperature in about twenty-eight minutes.. Being then put into a warm bed, he fell into a profufe perfpira- tion, which left him in his ufual health. One general remark will ferve for the pulfe in all thefe experiments. It was not poffible to keep the fubjecls of them from fome degree of previous agitation, and this al- ways quickened the pulfe.—The natural pulfe of Edwards was about 70 in the minute; but it may be obferved, that it was never under 85 before immerfion, and generally above it. However this might be, it invariably funk 1065, or from that to 68, in the water; became firm, regular, and fmall. After being long in the bath, it could hardly be felt at the wrift, but the heart pulfate 34, — 20, 9^ 96 96 9S 94 93' 94 93 94 924 ' This power of refilling cold ii not however general in infanity. iS8 He now got out into the air very flowly, and ftood in it three minutes, the wind not blowing on him. He loft one degree of heat at firft, which he recovered. He was then put into a warm bath at 90 deg. which at firft he felt warm, and his feet and hands were pained, but in two minutes he fell into a very violent fhiver, and his heat fell two degrees. The bath was then heated to 95 and 96 deg. but ftill he felt cold. It was heated to 99 deg. he con- tinued in it five minutes, and his heat was 91 deg. The heat was gradually raifed to 106 deg. when the fenfe of coldnefs, of which he had complained at the pit of the ftomach, gradually went off. Before this I had ufually kept him in the warm bath till his natural heat was nearly recovered, but after being half an hour in the heat of 106 deg. his own heat was ftill 93 deg. He now became fick and very languid, a cold fweat covering his face, his pulfe very quick and feeble. He was removed into bed, but paffed a feverifh night, and next day had wandering pains oyer his body, with great debility, refembling the be- ginning ftage of a fever. By cordials and reft this went off. This experiment clearly enough confirms the greater danger of being wet with frefh than falt-water; but in it- felf points out nothing certain befides, except that it is not to be rafhly repeated. I mean to try fome of thefe experi- ! ments to a greater extent on the brute creation, when I have procured thermometers better fuited to my views. The thermometers I employed had not a fufBcient mobility for very nice experiments, and I am well aware, that in parti- cular inftances, this may have milled me, though the gene- ral refults, which is all that is of importance in fuch expe- ments as thefe, will I hope, be found juft and true. Before I conclude, I muft offer a few obfervations on the fubject that led to thefe experiments. 1. It is, I think, already well known among feamen, that where there is only the choice of being wet with fait or frefh water, it is always fafeft to prefer the firft. In the heavy fhowers of rain, hail, or fnow, by which gales of wind are generally accompanied, the men that rrtuft be expofed to *59 them, ought, like Lieutenant Bligh and his crew, to wring their clothes out of fait water. 2. In all cafes where men are reduced to fuch diftreffes by fhipwreck or otherwife, that they have it only in their power to chufe between keeping the limbs conftantly im- merged in the fea, or of expofing them to the air while it rains or fnows, or of being expofed to it where the fea is at times wafhing over them, it is fafcft to prefer a conftant immerfion; becaufe, in the northern regions, where the cold becomes dangerous to life, the fea is almoft always warmer than the air, as the experiments of Sir Charles Douglas fhew; and becaufe there is not only a danger from the increafed cold produced by evaporation, but alfo from the lofs of heat by the rapid changes of the furrounding medium, as the foregoing experiments point out. 3. Whether, in high and cold winds, without rain or fnow, and where a fituation may be chofen beyond the reach of the waves, it is fafer to continue in the air, or to feek refuge in the fea, muft depend upon feveral circumftances, and cannot perhaps be certainly determined, The mo- tives for chufing the fea will be ftronger in proportion as the wind is high and cold, and in proportion as the fhore is bold. The foregoing narrative fhews, that men may furvive twenty-three hours immerfion in the fea, of the tempera- ture of 38 deg. or 40 deg,* (as great a cold as it almoft ever poffeffes), without food or water, and almoft without hope of relief; but that any man ever furvived an equally long expofure to the higher degrees of cold of the atmof- phere, in the fame circumftances, does not appear. Though in the cafe related, immerfion in water did not prevent thirft, yet there is little doubt that it alleviated it, a cir- cumftance of high importance towards the prefervation of life. I have purpofely avoided any reafoning on the caufe of the lofs of vital heat, on the change of media in the expe- • Thefe numbers ought I think to have been 33 deg. or 35 deg. See note, y. 142. i6o riments recited. It may be fuppofed that during immer- fion, the water immediately in contact with the fldn, ha- ving become heated to a certain degree, the naked body, on rifing from it into the air, was in fact expofed to a colder medium, and thus the lofs of heat, in this inftance, produced. My examination of the heat of the water during immerfion, not having been made in contact with the bo- dy, I will not deny, that there is fome foundation for the remark; and the cafes, it muft be allowed, are by no means exactly parallel between immerfion in an open vef- fel, however large, and immerfion in the fea, where the conftant undulation may be prefumed to occafion a con- tinual change in the furrounding fluid. But whatever al- lowance may be made for the circumftance mentioned, I am perfuaded, that the difference between the denfity of air and water being confidered, it is not fufficient to ex- plain the lofs of heat in the inftance alluded to. The changes of temperature in the living body are governed by laws peculiar to itfelf. I have found, in certain dif- eafes, greater and more fudden variations than any men- tioned, from applications of cold, very gentle in- degree, and momentary in duration. In his mafterly "Experiments and Obfervations on Ani- mal Heat," Mr. Hunter has objected to taking the heat of the human body by introducing the bulb of the thermo- meter into the mouth, becaufe it may be affected by the cold air in breathing. The objection is well founded if the bulb be placed on the upper furface of the tongue, but if it be put under it, and the lips fhut, the effects of refpiration may be difregarded, as I have found from many hundred ex- periments. The heat may be obferved in this way witheafe and certainty, by employing thermometers curved at that end to which the bulb is affixed, (the bulb being introdu- ced at the corner of the mouth), fome of which have been made for me by Mr. Ramfden, according to a form given, as well as others on Mr. Hunter's plan. From repeated trials it appears to me, that when the ufual clothing is on, the heat of the living body may be taken with nearly the fame refult, and equal certainty, under the tongue with the lips fhut, at the axilla with the arm clofe to the fide, i6i and in the hollow between the fcrotum and the thigh; every other part of the furface is liable to variation and un- certainty. It is evident, that of thefe three methods, the firft only can be employed, (as far as I can difcover), when the trunk of the body is immerfed in water; and even when the naked body is expofed to the cold air, the firft method feems the belt, the heat remaining mofl fteady under the tongue: the axilla is the next beft in order, and the worft the lower part of the groin ; for the fcrotum, and the parts of generation, lofe their heat on the application of cold, more fpeedily perhaps than any other part of the body, the extremities not excepted. The water employed in the experiments related, con- tained fait in the proportion of one to twenty-four. 1803. It was my intention to have repeated and enlar- ged thefe experiments, but the difficulty attending them, and the preffure of profeffional engagements, has hitherto prevented me. The two laft chapters have carried us off from the fub- ject of fever, to which we are about to return; it is hoped, that befides illuftrating fome of the more general effects of cold on the living body, they may affift us in a few obfer- vations on the nature of fever, and the mode of operation of the cold affufion, which it is the chief object of this publi- cation to recommend. 21 i6z CHAP. XVII. General View of Doclrines refpetling Fever.—Hippocrates, Galen, &c.—The Ideas of the Author refpetling the Nature of this Difeafe. THE great obftruction which men have in all ages ex- perienced in the purfuit of knowledge, has arifen from the promptitude of the human mind to decide in re- gard to caufes. To the weak and ignorant, prefumption is as natural, as doubt is intolerable, and with fuch, be- lief is almoft always a creature of the imagination. Nor do thefe obfervations apply to weaknefs and ignorance on- ly : to retain the mind unprejudiced and undecided, in the inveftigation of ftriking and interefting phenomena, till, by the painful fteps of induction, their hidden caufe is re* vealed, is an effort of the moft difficult kind, and requires the higheft and rareft powers of the underftanding. The records of every part of fcience bear ample teftimony to this truth, particularly the records of medicine, and in a ftill more jefpecial manner, that part of medicine which treats of the nature of fever. The moft eminent phyficians, in every period of the world, impatient of obferving and delineating, have been eager to explain, and even to fyf- tematize , and the fcience of life owes its corruptions more to the mifapplication of learning, than even to the dreams of fuperftition. Befides the theories derived from the fplen- did fictions of the Greek philofophy, various are the falfe doctrines introduced into medicine in modern times, and from the more certain branches of fcience. The principles of mechanics, of chemiftry, ofmagnetifm, and of electrici- ty, have in fucceffion been employed to explain the mo- tions of life, and have fcrved only to miflead and to de- ceive. Hippocrates, who lived at too early a period to be ac- quainted with the collateral branches of fcience, ftudied life and difeafe in the book of nature, and had the merit of an i63 original obferver. Perceiving the increafe of heat to be the moft remarkable fymptom in fever, he affumed this for the caufe, and founded his diftinctions of fevers, on the differ- ent degrees of the intenfenefs of this heat. He had not an inftrument that could meafure this exactly, and neceffarily trufted to his fenfations. In forming his diagnofis, he pla- ced his hands on the breafts of his patients, depending more to the degree of heat, than on the ftate of the pulfe, the nature and connexions of which he did not underfland. His practice appears to have been natural and judicious, and rounded on his theory. He directed linen, dipped in cold W2ter, to be applied to the hotteft parts; drew blood away both by cupping glaffes and the lancet; and admi- niftered cold water and cooling drinks, particularly barley- water and honey. This fimple practice will acquit the Coan fage with the candid and reflecting, of many of the idle theories which have been imputed to him, and which doubtlefs were the offspring of after times. In the days of Galen, philofophy and fcience had made fome advances, and the corruptions which he introduced into medicine from thofe fources are well known. Pre- ferving however the doctrine of his mafter, that heat was the caufe of fever, the practice of Galen, founded on this notion, was in fome refpects bold and fuccefsful, as was before obferved. To him fucceeded the Arabians, who ftill retained the original doctrine of Hippocrates, but with modifications and corruptions, by which the real na- ture of fever was ftill farther obfcured. In our own country, and in the laft century, arofe Sy- denham. He alfo was an original obferver, and to him medicine is doubtlefs much indebted. That he recorded fymptoms with great accuracy, that he eftablifhed many important facts as to the treatment of difeafe, and that he was a more cautious reafoner than his predeceffors or his contemporaries, are points that are indifputable. But though he affected not to theorize, he was a theorift in every page of his works, and though he founded his rea- fonings on what appeared to him felf-evident principles, yet time his proved them to be defective and fallacious. 164 It was the poftulate of Sydenham, that every difeafe ,s nothing elfe but an endeavour of nature to expel morbific matter of one kind or another, by which her healthy ope- rations are impeded. In this endeavour fhe is not to be obftructed, but affifted, and the procefs is to be carefully watched and promoted by which fhe accomplifhes her pur- pofe By one or other of the emunftones this is finally effected, and till it be effected, health cannot be reftored. Under this general notion, the inordinate adions of fever are perpetually compared to the motions of fermentation, by which nature feparates the vitiated particles from the blood previoufly to their expulfion. The dodrine of Sy- denham may be traced to remote ages ; under his fanction it fpread over Europe, and has defcended in one form or other to our own times. Sydenham's dodrine introduced the fyftem of Boerhaave, (to which we have already allu- ded), as well as other chemical theories of leffer fame, and the erroneous modes of treatment to which they gave birth. The inordinate heat, which Hippocrates confidered as the caufe of fever, in the eye of the chemifts, appeared na- turally enough, a neceffary, and within certain limits, a falutary confequence of the procefs excited by nature to ex, pel the difeafe! The dawn of a jufter pathology of fever is to be found in the works of Hoffman. Though he alfo undertook to be the interpreter of nature's intentions, he contemplated her procefs in fever with more fagacity, and rejecting che- mical and mechanical analogies, endeavoured to difcover the caufe of fever in the peculiar nature of the vital motions. He fuppofed the noxious caufe producing fever, (in the lan-« guagr of the fchools the remote caufe), to operate firft on the living folids, occafioning a general fpafm of the nervous and fibrous fyftem, beginning in the external parts, and proceeding towards the centre. In confequence of this, a contraction of me vt-ffels of the extremities muft of courfe take place, impelling the circulating fluids in an increafed ratio on the heart or lungs; which, ftimulating thefe organs to increafed action, the fluids are thereby repelled towards the extremities, and thus the phenomena of fever are pro- duced. There are therefore, according to Hoffman, two i6S diftind fets of motions in fever, the firft from the extre- mities towards the centre, arifing immediately from the fpafm, and accompanied by a fmall pulfe, anxiety, and oppreffion ; the fecond, from the centre towards the furface, which is the effort of nature to refolve this fpafm; and marked by a full, ftrong pulfe, and increafed heat. The firft of thefe fets of motions are baneful, and fometimes fatal; the fecond are medicinal and falutary. By thefe views the phyfician is to be direded in counterading the morbid adions, and affifting the fanative procefs of na- ture.* Since to theorize feems to be the irrefiftible propenfity of men of genius, this theory of the celebrated Hoffman, which accords with appearances, and has a confiderable connexion with pradice, may be allowed the tribute of applaufe. The fyftem of Hoffman, produced that of Cullen, which may perhaps beconfidered as the prevailing dodrine at prefent, when however theory of every kind has loft much of its weight on mature underftandings. According to Hoffman, the firft effed of the remote caufe of fever is the fpafm, producing a re-adion, as has already been mentioned. Dr. Cullen introduced a previous link into the chain—He contended, that the firft effed of the noxious effluvia, (the remote caufe), was a general debility, afleding the fenforium commune. To this debility he at- tributed the fpafm, and to the fpafm the re-adion of the heart and arteries; which re-adion, continuing till the fpafm is refolved, removes the debility and the difeafe. According to Hoffman, the fpafm belongs to the clafs of motions that he denominates baneful; but Dr. Cullen prefumes it to be falutary, and therefore afcribes it, in the language of the fchools, to the vis medicatrix natura. It is not my purpofe to appreciate thofe changes introduced into the theory of Hoffman, or to attempt to eftimate with precifion, the Cullenian dodrine of fever, as it arranges phenomena, or applies to pradice. Debility of a peculiar kind, fpafm, and re-adion of the heart and arteries, feem * See Hoffman's Works, vol. i. torn, ii, page to.—Geneva Edition. 166 all of them links in the chain of fever, and in the firft lines of Dr. Cullen, the hiftory of the difeafe is recorded with extraordinary minutenefs and accuracy. I bow with refpect and fenfibility to the genius of this illultrious man ; but his dodrine feems erroneous, in as far as it enters into the fuppofed intentions of nature, and defedive, in paffing over the morbid heat, and the morbid affociation, whiclj form the fucceffive links of the chain. This dodrine of fever, as well as all the other dodrines of its celebrated author, was affailed by Dr. Brown, Af- fuming the exiftence of an unknown principle, as inherent in the living fibres, to which he gave the name of excita- bility, he explained all the phenomena of life and difeafe, by means of this principle, aded on by ftimuli. Thefe ftimuli, applied in the due proportion, produce the juft degree of excitement, that is, the ftate of health. If the ftimuli are diminifhed below the healthy proportion, he fuppofed the excitability to accumulate; if increafed beyond this proportion, he fuppofed it to be expended; and on thefe different conditions he attempted to found a general theory of difeafe. Difeafes he divided into two claffes, Sthenic and Afthenic, or difeafes of increafed and of diminifhed excitement, in the latter of which claffes he placed typhus, the fever of which we treat. In the excitability, Dr. Brown admitted of no change, except in regard to quantity; in the excitement, no variation, except in regard to ftrength; and in all univerfal difeafes, he fup- pofed the whole fyftem to be equally affeded.* Having therefore affigned to fever its place in his feries of defend- ing excitement, he refufed to inquire into its fymptoms, or to enlarge on its treatment. It is evident, that fuch a theory could embrace none of the charaderiftics of the difeafe. Debility, the firft link in the chain of Dr. Cullen, formed according to Dr. Brown the effence of fever. The exiftence of fpafm he denied, re-adion he derided, and the morbid heat and morbid affociation, he wholly overlooked. It is not however to be difputed, that his general views of difeafe had a falutary influence on the pradice in typhus, * This was his general pofition ; it is true he relaxed a little from it in his explanations. 167 by encouraging a more liberal ufe of wine and opium, re- medies of the utmoft importance, and now univerfally adopted. The various modes of adion of the living principle, or to ufe his peculiar language, of the fenfbrial power, which were unknown to Dr. Brown, have been obferved and il- luftrated by the author of Zoonomia. In the theory of fever delivered by Dr. Darwin, the in- fluence of morbid affociation is very fully explained. 1 am not however difpofed to adopt this theory, which the learned and candid author himfelf confiders as incomplete, becaufe it affumes the truth of his peculiar dodrines, to which it cannot be expeded that a hafty affent fhould be given—confidering their vaft extent and importance, and confidering alfo, that many other fabrics of genius of the fame kind, have crumbled down into the fand of which they were formed.* Difmiffing therefore, as far as it is poflible, all theories from the mind, let us briefly confider the procefs of nature in fever, and examine what inferences may be fafely drawn from the fucceffion and catenation of the leading fymptoms, and the remedies which experience has pointed out as moft fuccefsful. Our obfervations muft of courfe be confidered as applying to the typhus, or low contagious fever of Bri- * »«What I have thus delivered, I beg to be confidered rather as obferva- " tions and conjectures, than as things explained and demonftrated ; to be '« confidered as a foundation and a fcaffokling, which may enable future in- " duftry to erect a (olid and a beautiful edifice, eminent both for its fimpli- " city and utility, as well as for the permanency of its materials—which may " not moulder, like the ftru&ures already erected, into the fand out of which " they were compofed ; but which may (land unimpaired like the Newtonian " philofophy, a rock amidlr the wafte of ages !" Zoonomia, 'vol. ii. p. 625. Much as I admire the fingular ingenuity of Dr. Darwin, thepofition com- mon to him and Dr. Brown, that the fenfbrial power, or excitability, is a fubfiance which accumulates and diminiffees in the inverfe ratio of the Simu- lation, on which his docliines of fever are founded, has not my affent. On the contrary, it appears to me, that whatever the nature of the vital energy, (the fenforial power or excitability) may be, it does not ait in a way that ad- mits the relations of quantity to be applied to it, and the contrary doctrine, which introduces into the fyftem of Dr. Darwin fo many epicycles, feems to me the mortal part of his woik. I am aware that Dr. Darwin holds the doctrine mentioned with certain modifications; which however do not appear to nit fatisfactory. i68 tain, more particularly, but generally to all idiopathic fe- vers ; and if they lhould be found as little fatisfadory in their relult, as the conclufions of others, the learned and can did reader will not, it is hoped, fuffer his opinion of the accuracy of the author's fads to be affeded by the fal- lacy of his reafonings but extend his forgivenefs to one other abortive attempt to illuftrate the nature of fever, an important, but difficult and long contefted fubjed. Medical fcience has not afcertained the various remote caufes which may produce fever, and I avoid this inquiry, on which I have nothing new, that is fatisfadory, to offer.* The firft fymptom of the difeafe is a debility or languor, very diftindly expreffed on the countenance, followed by palenefs, fenfe of cold, and tremor; the fundions of the mind are weakened in a correfpondenr degree with thofe of the body, and all the adions of the fyftem feem enfeebled. This general debility is peculiar in its kind. The fymp- toms refemble thofe produced by inhaling certain gafes, whofe properties are known; and this circumftance gives fome fupport to thofe notions of the nature of contagion, which the new chemiftry has fuggefled. They feem alfo to have a refemblance, though a more remote one, to the effeds of certain poifons operating on the ftomach, or in- troduced into the ciiculation by the abforbents. The re- mote caufe of fever itfelf, may perhaps be confidered as a poifon, ading diredly on the fenforium commune. Where this poifon is concentrated very much, and highly malig- nant, or where the fyftem is much debilitated, the powers of life are fometimes oppreffed and extinguifhed in the firft ftage of the difeafe. In general however, a re-adion or re- fiftance commences; the heart and lungs are roofed into increafed exertion by the preffure of the accumulating fluids, and repel them back on the furface and extremities; while a fpafmodic, or morbid ftridure of the extreme veffels, op- pofes the reflux of the fluids, and thus maintaining the in- ordinate preffure on the centre, excites the heart, arteries, * In confining the remote caufes of fever to contagious human effluvia,and to marfh miafmata, Dr. Cullen probably fimplified too far. Cold, under cer- tain circumftances, feems to produce fever, and the conftitution feem* at times to fall into fever from unknown and internal caufes, 169 and lungs, to ftill more violent exertions. In this conteft the ftomach is ufually brought into fympathy, and naufea and vomiting are often induced. This conftitutes what appears to be a ftruggle between the living energy, and the morbid caufe—between the power of the centre, and the refiftance of the extreme veffels—in the courfe of which, a degree of preternatural heat is generated, and the phenomena of the hot ftage are produced. When the powers of life prevail, the ftridure on the extreme veffels, and on the exhalents of the fkin, at length gives way, and a profufe perfpiration being poured out on the furface, the heat is carried off, and the febrile fymptoms fubfide. Without entering into detail, this may be confidered as a general view of the fingle pa- roxyfm. It often however occurs, that the folution of the ftridure on the extreme veffels does not take place, or is incomplete, and that the morbid heat is not carried off. In this cafe the morbid adions go on, and the difeafe runs into continued fever. For fome time the ftridure on the extreme veffels remains, and the heat is preternaturally great; but thefe fymptoms do not continue through the whole courfe of the difeafe. On the contrary, the heat towards the latter ftages, will fometimes be found as low as the natural ftandard, fometimes lower, and the capilla- ries of the fkin be completely relaxed; while the inordinate adion of the heart and arteries continues, being carried on, as it feems to me, by the morbid affociation produced in the courfe of the difeafe, which retains its influence in this, as in other cafes, after the caufe that produced it, ceafes to operate. To this general view of fever, it is probable that little objedion will be offered, by thofe who are familiar with the difeafe. But exceptions may be taken to the language, as not kifficiently clear of theory, againft which the author had declared. It may be faid, for inftance, that in apply- ing the adive forms of fpeech to the re-adion or refiftance of the conftitution, we feem to run into the Stahlian doc- trine, or at leaft to affume the exiftence of the vis medica- "v.v r.atnra of Dr. Cullen; and that to enumerate fpafm 11 170 as a link in the chain of fever, is in fad to admit the lead- ing peculiarity of his fyftem. To this it may be replied, that there, is no fubjed on which the imperfedion of lan- guage is fo much perceived, as in our attempts to defcribe The phenomena of life. In the ftridnefs of fpeech we pro- perly employ the paffive mood of our verbs, in recording the phenomena of inanimate matter, and confine the active mood to thofe vital motions, which are accompanied with confcioufnefs or defign; but there are various adions pe- culiar to life which are not accompanied by confcioufnefs, or fubjed to the will, and which depend on laws wholly diftind from thofe which regulate inanimate matter. If we borrow the phrafeology and the mood in which we fpeak of inanimate matter in recording thefe adions, we are apt not only to form indiftind conceptions of their nature, but to apply the principles which regulate inanimate motions to the motions of life. This is an obvious, and as expe- rience teaches us, an ample fource of error. If, on the other hand, we employ the adive forms of fpeech, thefe immediately fuggeft confcioufnefs and defign, and the ima- gination forms to itfelf an ideal being, as direding thefe adions, in whom confcioufnefs and defign may refide. This alfo is a natural and fruitful fource of error.—Both thefe extremes we would avoid. But the penury of lan- guage obliges us to ufe one or the other mood in treating of the phenomena in queftion; and on refledion it appears, that in our prefent ignorance of the firft principles of life, a clearer notion will be formed of the nature of thofe mo- tions in which the whole fyftem fympathizes, deflitute though they be of confcioufnefs and defign, by the occa- fional ufe of the adive forms of fpeech, fince they have a much ftrider analogy with thofe vital adions, to which thefe forms are juftly applicable, than with the motions of inanimate matter. Confederations of this kind may have influenced the late John Hunter in the ufe of his terms, which are chiefly atlive, and which, though far from per- fed in themfelves, are more happy than thofe of former phyfiologifts, as his dodrines of life were more original, more unprejudiced, and in general more accurate and pro- found. I7I Debility of a peculiar kind, is then the firft operation of the remote caufe producing fever—the neceffary confequence, or as fome contend, the concomitant effetl, is a fpafm, or contraction of the arteries; but more efpecially of the ex- treme veffels, and the capillaries of the furface—hence fol- lows an accumulation of blood on the heart and lungs—the re-atlion of thofe organs—the generation of morbid heat— and of morbid affociation. On each of thefe links in the chain of fever, let us offer a few remarks. i. It has been afferted by fome inveterate theorifts, that the debility in fever has nothing in it peculiar. It is enough to reply, that Ample debility often exifts even in extreme degrees, without producing the phenomena that conftitute fever. 2. It has been afferted, that a fpafm on the extreme vef- fels does not exift in fever, or that if it does exift, it may fafely be difregarded. Thofe who hold the firft opinion, fuppofe the palenefs and fhi inking of the furface to arife merely from the enfeebled circulation, by which the blood is not propelled into the extreme parts; and doubtlefs this has its effed. In fyncope, however, where this palenefs and fhrinking arife from pure debility, as foon as the heart and arteries recover their energy, the blood flows immedi- ately back into the extreme veffels as before. That this is not the cafe in fever, the moft curfory obfervation will convince us. After the re-adion of the heart and arteries has been fome time eftablifhed, the blood is indeed pro- pelled through the veffels of the furface that circulate the undivided fluid; but the capillary arteries that feparate the aqueous part, remain conftrided, as well as the orifices of the fkin that pour it out on the furface. 3. It is however contended, that this ftridure may be difregarded, fince it is now very generally admitted, that the perfpirable matter is not excrementitious, and fince we find that its obftrudion in other circumftances, and from other caufes, produces little or no injury to the conftitution. A little refledion will ferve to refute this pofition. Spafm, or morbid ftridure on the extreme veffels, muft neceffarily effed the condition of the heart and lungs, from the increaf- 172 ed preffure of the circulating fluids on thefe organs: it muft alfo affed the ftomach, not only from the connexion of that organ with the heart and lungs, but from its dired fympa- ' thy with the furface.—Dr. Cullen has put thefe points be- yond controverfy. But this is not all; the obftrudion of perfpiration—of profufe perfpiration—in the paroxyfm of fever, obftruds the procefs by which the conftitution ex- pels the morbid heat, and thus leaves the fyftem under the influence of a general ftimulus of the moft powerful nature. It was a pofition of the celebrated Boerhaave, that the morbid heat in fever, being a fymptom only, might there- fore be difregarded.—But can we fuppofe, that a heat, fix or feven degrees greater than that of the blood in health, i however generated, will not have the moft important ef- feds on the fyftem, and if it ftands in the relation of effecl to the preceding fymptoms, that it will not operate as a caufe on thofe which facceed ?—Doubtlefs this morbid heat re- ads on the vafcular fyftem; irritates the fpafm of the ex- treme veffels; and prolonging the increafed adion of the heart and arteries, eftablifhes a morbid affociation, which carries on this increafed adion after the fpafm has relaxed, and the heat itfelf fubfided. 4. What then, it may be inquired, is the adual ftate of the animal heat in the different ftages of the paroxyfm of intermittent, as meafured by the thermometer ? In differ- | ent trials it feemed liable to confiderable variety, but the ( following is the general refult, which however the reader | will receive, as fubjed to the corredions that a more ex- tenfive experience may fuggeft. In the cold ftage, the heat is dimifhed, not on the furface only, as fome have imagi- ned, but very probably over the whole fyftem. I have found it under the tongue, and at the axilla, as low as 94 deg. 93 deg. and 92 deg; and on the extremities many degrees lower. At this time the ftomach feels cold, and univer- fal tremor takes place. Warm, and even hot liquids, are highly grateful, and the warm bath, heated to 100 deg. more grateful ftill. The drinking of warm liquids fhould be freely indulged in, and there is reafon to believe, that immerfion in the warm bath, as pradiced by Galen, would be found as falutary as it is grateful. By degrees the pulfe J73 increafes in frequency and force, and the heat begins to rife, but with much irregularity. It doubtlefs accumu- lates firft in the centre of the fyftem, and from the centre is pufhed along with the blood, towards the furface. This procefs does not however go on in any regular progreffion, but like almoft all the other animal pioceffes, with alter- nate increafe and relaxation. At times it appears retro- grade; and even when it is fo far advanced that the heat taken at the axilla, and under the tongue, is greater than the ftandard of health, a flight acceffion of external cold will produce a general chillnefs, and bring back the op- preffion on the heart and lungs. On the furface itfelf the reftoration of heat takes place with no regularity. Certain parts are heated firft. In certain parts the heat is above what is natural, while in others, it remains below this ftan- dard ; and hence arifes that mixed fenfation of heat and cold, which every one acquainted with fever muft have experien- ced in the tranfition from the cold to the hot ftage of the paroxyfm. The irregularity with which the heat of the furface is reftored, probably arifes from this circumftarice, that two caufes conjoin in producing this effed—the reflux of warm blood from the centre, and the fympathy between the fto- mach and fkin. To this laft is attributed the circumfcribed heat of certain parts of the fuiface, while the reft remains cool, this local heat being probably excited by the in- creafed adion of the veffels of thefe parts, awakened by the reftored heat and tone of the ftomach, which in other circumftances produce fimilar effeds. In general the fenfe of cold predominates even after a morbid heat has taken place at the axilla, under the tongue, and in different parts of the abdomen and thorax; becaufe a confiderable part of the furface, and the whole of the extremities, ftill re- main below the natural temperature, and the fenfation which this produces, arifing from parts of great fenfibility, overcomes the fenfation of heat from the deeper feated parts, whofe fenfibility is fo much inferior. At length however the heat of the furface becomes general and uni- form, rifing to 102 deg. 103 deg. 104 deg. and fometimes ro5 deg. of Fahrenheit. I have not feen it higher than *74 this laft degree in the paroxyfm of intermittent, and fel- dom in continued fever; though different authors fpeak of febrile heat four, or even five degrees higher. The fen- fation of heat is now ftrong and fteady, and the acceffion of external air does not produce a chillinefs as before.—This is the time for the affufion of cold water, as has already been mentioned. The fenfation of heat is moft powerful on the extremities, particularly on the palms of the hands and the foles of the feet.—This arifes in fome degree from the great fenfibility of thefe parts, but in fome degree alfo from this circumftance, that in their natural ftate they are two or three degrees cooler than the trunk of the body, and j cannot be raifed to the general temperature of health with- out an uneafy fenfe of heat, which is frequently relieved by a partial perfpiration. When raifed to the general fever heat, their temperature is therefore increafed in more than a proportional degree beyond its ufual ftandard. After remaining fome time in this hot ftage, the fkin begins to relax, and to become fofter and fmoother to the touch; infenfibly a moifture takes place, terminating generally in a profufe fweat. Neither however does this procefs go on regularly; after the moifture commences, it fometimes goes off, and a dry burning ftate of the fkin re- turns : again the fweat commences, and when it becomes general, and continues fteady, it is critical, that is, it terminates the paroxyfm. As it commences, the heat de- clines, though at firft very flowly ; as it proceeds, the heat fubfides gradually, and when it terminates, the tempera- ture of health is reftored. The finking of the morbid heat is however a good deal regulated by the quantity of the bed-clothes, and the clofenefs with which the body is en- veloped.—Where the whole covering that was laid on during this cold ftage is kept on during the hot ftage, (as often happens, through a miftaken wifh to force the fenfi- ble perfpiration), the heat is carried off with difficulty, and it requires the perfpiration to be very profufe to reduce it to its natural ftandard. On the contrary, if the clothes be leffened after the hot ftage is fairly eftablifhed, the heat paffes off with lefs difficulty, and the perfpiration rcquifue to remove it is much lefs profufe. l7S Thefe details will not be thought fuperfluous or tedious by thofe who confider, that after all that has been written on the fubjed of fever, thermometrical obfervations on the rife and progrefs of febrile heat are in a great meafure new.* 5. Whether it be owing to the nature, or force of the contagion, to the ftate of the conftitution, or to fome other unknown caufe, the re-adion of the fyftem does not always refolve the fpafm or morbid ftridure on the extreme vef- fels. When this ftridure is not refolved, the fweat is not effufed, the morbid heat is not carried off", and the difeafed adions run into continued fever. If a perfon is confined in a hot room, or in the hot bath, till his heat rifes three or four degrees above the natural ftandard, his pulfe will be found of a feverifh rapidity ; wandering pains will foon be felt over the body ; langour, laffitude, and at length great debility will take place, with moft of the fymptoms of regular fever. It is evident that thefe fymptoms cannot be expeded to go off till the inor- dinate heat is removed, and if the perfon remain fome time in the heated medium, he will find, that the inordinate adion of the heart and arteries continues after leaving it, and even after his own heat has fubfided to its natural ftandard. This depends on a principle peculiar to life, to which the name of habit, or affociation, has been given, and which extends its influence to all the vital phenomena, whether intelledual or corporeal. In fever this morbid heat docs not arife from the fur- rounding medium, but from certain motions in the fyftem itfelf. But however generated, a heat five or fix degrees above the natural ftandard muft be a powerful agent, and it cannot be expeded that the difeafed adions lhould fub- fide under fo ftrong a ftimulus. The rapidity of the cir- culation, and the labour of refpiration, are confequences of a heat of this degree from whatever caufe arifing, and muft continue till the heat is reduced. * I intended to have introduced here one or two regifters of the heat and pirle, taken eveiy half hour during the paroxyfm of intermittent, but this is delayed till I am enabled to fpeak from more numerous obfervations. 176 We mav here obferve, that it is not by any means eafy to make an accurate comparifon between the ftate of the fyftem under the heat of fever, and under an equal degree of heat introduced from the furrounding medium, becaufe it is in fad very difficult to raife the heat of the body in a ftate of health to the higheft degree of fever heat, either by heated air or heated water. The experiments recorded by Sir Charles Blagden prove this in refped to a heated at- mofphere; the heat, as it is accumulated in the fyftem, being diffipated by profufe perfpiration, or by fome other living procefs, of which perfpiration is a concomitant ef- fed. I have found the fame difficulty in heating the body j in the hot bath, for there alfo the heat is with difficulty 1 increafed beyond 100 deg. or 101 deg. when fweat, as is ufual, breaks out over the furface. Even in thefe de- grees the greater part of the fymptoms of fever will be felt, The heat however is moderated, and, when the temperature of the external medium is reduced, it is carried off by the difcharge from the furface. But in fever this is prevented, for the peculiar debility induced by the remote caufe, occa- fions, or is attended by, a fpafm, or morbid ftridure of the capillaries of the furface and of the fkin itfelf, by which the infenfible perfpiration is prevented from increafing in proportion to the heat, and the fenfible perfpiration ob- ftruded. Hence the difficulty of reducing the heat in fever; and thus it appears, that the fpafm on the extreme veffels, which fome of our lateft phyfiologifts have wholly neglected, is perhaps the moft important peculiarity of the difeafe. It may be obferved, and it furnifhes a fubjed of in- terefting inquiry, that this ftridure, which often gives way under a moderate re-adion, maintains itfelf with rigidity where the re-adion is great. Thus, where the heat rifes to 99 deg. 100 deg. or 101 deg. the orifices of the fkin often relax, and carry it off by increafed perfpiration; while at 104 deg. and 105 deg. with a proportionable force of circulation, they are in general obftinately con- ftrided. This is very ftriking in fever, but not peculiar to it. Even in the ftate of health, while a moderate, gradual, and general ftimulus from heat opens the pores 177 of the fkin, a fudden and confiderable increafe of heat conftrids them ; the violence of the ftimulus, in this, as in other inftances, occafioning a morbid refiftance of the living fibre on which it ads. This refiftance to inordinate ftimuli extends to every part of the living fyftem, and be- longs to every fpecies of vital adion—it may be confidered as peculiar to life. But it may be juftly remarked, that after fever is efia.. blifhed, the redudion of heat to the natural ftandard, how- ever defirable, is attended with difficulty and hazard, fince the patient cannot in general bear the continual ex- pofure to external cold neceffary for this purpofe. Even in the hot ftage of fever, if the patient be expofed naked to a cold atmofphere, though he fupports the appli- cation for fome time with comfort, and even with advan- tage, yet, as the heat of the furface approaches the ftan- dard of health, a fudden fenfe of chillinefs comes on, with a return of oppreffion on the heart and lungs, and all the fymptoms of the firft ftage of the paroxyfm. The length of application, and the degree of external cold pro- ducing this effed, are indeed various in various conftitu- tions, and in different ftages of the difeafe: the degree of re- dudion of the animal heat at which the chillinefs commences, is alfo uncertain ; but the general truth of the pofition laid down is eftablifhed on ample experience, and will not, I believe, be controverted. In cooling the furrounding at- mofphere in fever, or in any other continued application of cold, care muft be taker* to keep it within the limits in which it is grateful to the fenfations ; and within thefe limits the cool treatment, as far as my obfervation extends, is uniformly advantageous. But though it moderates re- adion, it does not in general remove the fpafm on the capillaries, or break the affociation or habit by which fever is prolonged. This is effeded by the fudden affufion of cold water over the naked body; and the mode of its operation will now be eafily underftood. The fudden, general, and power- ful ftimulus given to the fyftem, diffolves the fpafm on the extreme veffels of the furface, and of the various cavities ^3 178 of the body; the fudden and general evaporation carries off a large portion of the morbid heat accumulated under the fkin, and the healthy adion of the capillaries and exha- lents being reftored, the remaining fuperfluous heat pafTes off by fenfible and infenfible perfpiration. The ftimulus of morbid heat and of morbid ftridure being removed, the morbid affociation feems alfo broken by the fudden and powerful impreffion on the fenfations—in fad, the inordi- nate adion of the heart and arteries fubfides, and the har- raffed and toil-worn patient finks into that peaceful fleep which nature has provided as the folace of our pains and forrows, and the reftorer of our ftrength. If fueh be the explanation of the diminution of the heat, and of the frequency of the pulfe, which follow the affu- fion of cold water on the furface, it may here be inquired how the diminution of the thirft is accounted for. Are we to fuppofe, that a portion of the liquid is taken up by the abforbents of the furface, as is generally believed to be the cafe, during immerfion in the bath? I apprehend not. The abforption in the bath, if it occur at all, of which there is no fufficient evidence, has been greatly exagge- rated ; and the diminution of thirft, after the cold affufion, is too fpeedy to be afcribed to fuch a caufe. It admits of a more fatisfadory explanation. The morbid ftridure on the extreme veffels, to which we impute fo much, is not con- fined to the capillaries of the furface, but extends, as far as we have an opportunity of obferving, to the capillaries of all the cavities of the body.. The fenfe of thirft is pro- duced by the heat and drynefs arifing from the morbid ftridure of the exhalents in the inner furface of the mouth, fauces, and ftomach ; and this ftridure, being removed by the affufion on the furface of the body, from the fympathy between the furface and thefe cavities fo often alluded to, the healthy adion of the exhalents of thefe parts, as well as thofe of the fkin, is reftored; and their moifture being poured out, the heat and drynefs are removed, and the thirft diminifhed. This indeed feems to be the way in which thirft is re- lieved in the firft inftance, by liquids taken into the fto- 179 mach itfelf, where the effeds is too fudden to arife from the abforption of any portion of the liquid into the mafs of circulating fluids. We cannot indeed perceive this effed on the exhalents of the ftomach, but we may reafonably fuppofe it to take place where we obferve the fwallowing of drink to be followed by a relaxation of the exhalents on the fkin, which muft proceed, from their fympathy with thofe of the ftomach previoufly relaxed; and it may illuf- trate and fupport this pofition, that when liquids, fwal- lowed even in large quantities in the hot ftage, do not produce a fenfible increafe of perfpiration on the fkin, the relief they afford to the thirft is momentary only. In fuch cafes we prefume the ftridure on the exhalents of the ftomach has nOt been refolved. The relief from thirft afforded by liquids taken into the ftomach is in general however more effedual and complete than from affufion of water on the furface, becaufe, when the ftridure on the capillaries is removed, a rapid abforption takes place from the ftomach, and the circulating fluids are diluted. But on the furface of the body this abforption is doubtlefs flow and imperfed, and it will afterwards be Ihewn, that there is reafon to doubt whether it takes place at all. It was remarked that the affufiGn of tepid water on the furface, though effedual in diminifhing heat, (page 66), is not fol- lowed by the entire ceffation of fever, as is often the cafe after the cold affufion. The caufe of this is obvious—the coolnefs produced by the tepid affufion arifes from the in- creafed evaporation, and continues only while this conti- nues. The ftimulus given by the tepid affufion is compa- ratively flight and tranfient—it does not refolve the fpafm on the furface, or on the other cavities of the body, and it does not deftroy the morbid catenation. The heat there- fore fpeedily returns, when the remedy is withdrawn. This explanation of the operation of the affufion of cold water feems to me fatisfadory. The cafes which have been related fhew, however, that it is only in the early ftages of fever that it produces a folution of the difeafe. In the after ftages, though uniformly advantageous while the morbid heat continues, its effeds are not fo decifive, the morbid adions having acquired the force of habit, or in other i8e words being carried on by the affociations that have been produced. What then ought to be the indications of pradice in fcr ver ? To diminifh the cold in the cold ftage; to mode- rate the heat in the hot ftage, and to refolve the ftridure on the extreme veffels by which the morbid heat is retain- ed, and the re-adion prolonged; and where the inordinate adion of the vafcular fyftem continues after thefe objects have been attained, to fupport the powers of life till the morbid affociations, or habits of adion, gradually die away, from the removal of the caufes by which they were introduced. Jn addition to thefe general indications, it will be effential tx> fecure the proper adion of the bowels, and in every cafe to unload the alimentary canal of its mor- bid contents, whether thefe contents have become difeafed through the adion of general fever, or, as there is reafon to believe in fome of the fevers of the warm climates, by the remote caufe by which fever is produced. If thefe general obfervations fhould excite attention, they will doubtlefs excite objedions alfo, and perhaps ani- madverfions; but whatever be the fate of his reafonings, the author refts with fome confidence on the ftability of the fads by which they have been fuggefled. In the view which he has taken of fever, the fuppofed intentions of nature are not inquired into; and of courfe no attempt is made to arrange the fymptoms as they arife from the dired agency of the febrile poifon, or the exertion of her medi- cating power. Such attempts are as unneceffary as they are difficult. It is not indeed to be denied, that the living fyftem, after being excitrd into morbid adion, paffes fre- quently unaffifted, through a fucceffion of fymptoms into a ftate of health, differing in this as in every other refpecl, from any of the arrangements of inanimate matter. But it is equally true, that it often finks in the courfe of this procefs, fometimes deftroyed in fever by the excefs of its Own re-adion, and fometimes by the habits of adion or affociations produced in the courfe of the difeafe. It is a ferious error to fuppofe that the febrile poifon, if fo we may call it, being received into the fyftem, is the i8i principal caufe of the fymptoms, and that they confift of a ftruggle of nature to expel it, without which health can- noc be reftored. It is fafer to confider it as an agent that excites the fyftem into fever, which however is carried on, not by the continued prefence and agency of this agent, but by the principles which regulate the adions of life. We are not therefore to wait for the fanative procefs by which nature is fuppofed to feparate this virus, and to throw it off, watching her motions, and affifting her pur- pofes; but to oppofe the fever in every ftage of its progrefs with all our (kill, and to bring it to as fpeedy a termina- tion as is in our power. When we difpel the morbid heat, and reduce morbid re-adibn in the hot ftage of the origi- nal paroxyfm, by the powerful means of the cold bath af- fufion, the whole of the febrile fymptoms vanifh; a fuffi- cient proof, that in this ftage of the difeafe, thefe fymp- toms arofe from inordinate heat and inordinate adion, and not from a poifon circulating with the blood.—Hence the fafety and the wifdom of decifive meafures in the earlier ftages, before the ftrength is materially impaired, or the difeafed habits eftablifhed. Thofe who pradife within the tropics, where fever runs its dreadful courfe with fuch ra- pidity, ought efpecially to be aware of this truth, with which indeed the moft intelligent of their number feem now to be impreffed. In thofe climates, however, the difeafe ought to be combated, not merely by affufion of cold water on the furface, but by immerfion of the patient in the cold bath. In this fever, hours, nay minutes are precious, and as the cold ftage is fhort, the application of this remedy admits little delay. As foon as the fecond, 1 or hot ftage is formed, a judicious and refolute application > of cold might fuperfede all other remedies. But the tem- perature of the fea, and even of the fprings within the tro- pics, rifing generally as high as 77 deg. or 78 deg. of Fahrenheit, affords a ftimulus to the fenfations from fimple affufion, of a weaker kind, and hardly permits us to hope, that in the form of affufion, the cold bath can be followed by thofe effeds in the ardent fever of the torrid zone, which in the milder fever of this climate it fo happily produces. Artificial modes of cooling the water may in- l82 deed be reforted to, and when this can be effeded, the re- seated ufe of the affufion may in all probability extinguifh the difeafe. But on military duty, as well as in moft other fituations, artificial methods of cooling a fufficient quanti- ty of water it may often be impoffible to employ. In fuch cafes, when the phyfician has afcertained that the heat of his patient has rifen to the degree which juftifies the prac- tice, let him plunge him fearlefsly into the cold bath, or the fea. The duration of immerfion muft depend on the effeds on the pulfe, on the fenfations, and on the heat, meafured by the thermometer; and a greater degree of coolnefs will be produced by alternately raifing him into the air, where the wind blows over his naked body, and finking him into the water, than by continued immerfion. The utmoft care is neceffary in a procefs of this kind, to ouard againft the effeds of fatigue. Various inftances might be adduced of the fuccefs of this pradice in perfons who have, in the delirium of fever on fhipboard, plunged into the fea. I have received a variety of authentic rela- tions of this nature. Thefe have happened on board of our fhips at fea, during the delirium of fever, and chiefly in the warm climates; and in every inftance where the pa- tient has been fortunately taken up, recovery has followed, An accident of this kind occurred about three years ago to Captain S****, of this port, in the Irifh channel, H< fprang out of his cabin window in the height of deliri- um, and was upwards of twenty minutes in the water- He was taken up perfedly calm, and fpeedily recovered. —If it be confidered, that in the Irifh channel, even in fummer, the temperature of the water is feventeen or eigh- teen degrees colder than in the Weft Indies, the importance of this fad will be clearly perceived. But while the dif- ferent modes of applying cold water to the furface are em- ployed, it ought alfo to be poured into the ftomach in large quantities, when the patient's heat will permit it, and the prefence of naufea and vomiting is no objc&ion to this pradice, if a chillinefs of the ftomach is not produced. When we confider the general adoption of cold drink in the ardent fever of the ancients, its fuccefs in the Hunga- rian fever, to which the yellow fever bears fuch analogs i83 and the pointed recommendation it has received from Hoffman in bilious vomitings and dyfentery, it appears rather extraordinary that it has not hitherto been reforted to in the difeafes of the Weft Indies. The falutary effeds of the cold bath, and of cold drink in fever, ftrongly recommend the adoption of thefe remedies in the plague. On the northern and eaftern fhores of the Mediterranean, where the liberal ufe of cold drink in fe- vers prevailed throughout antiquity, and on fome parts of which it feems to have been carried to a great extent in the beginning of the prefent century, there is reafon to believe that it has now fallen into difufe. If we give credit to the anfwers made to the queries of Mr. Howard in regard to the treatment of the plague, the adminiftration of cold drink forms no part of the regular pradice in that terrible difeafe. The Jew phyfician of Smyrna indeed fays, " that " the Turks, in the violence of the fever, take handsfull tf of fnow and apply it over their bodies, and alfo eat, it; " and likewife fometimes throw cold water on their feet." But the learned Hebrew cannot determine whether it is of fervice, " as thefe people in other refpeds pay no regard " to the rules of diet. Howard on Lazarettos, page 39. Morandi, phyfician at Venice, obferves, " that fome failors " at Conftantinople, in the phrenzy of the plague, have* " thrown themfelves into the fea, and it is faid, that on ce being taken out, they have recovered." But this happy temerity the regular praditioners do not appear to have imitated, a fad that is further eftablifhed by Dr. Ruffel, in his account of the treatment of the plague at Aleppo.* The adminiftration of cold drink in the plague, as well as the external application of cold water, muft however be regulated by the adual ftate of the patient's heat, and of his fenfations of heat, of which alfo we have to lament that we have no accurate information. If it fhould be * When Mr. Howard was printing his work on Lazarettos, at Warring- ton, in 1788, I communicated to him an account of the fuccefles of our firft trials of the affufion of cold water in fever, in the Liverpool Infirmary, and he promifed to make more particular inquiries in regard to the empyrical ufe of this remedy, in his enfuing journey to the Eafc, in the earlier part of which, it is well known, his career of benevolence terminated, 184 found that in this malignant difeafe, the heat is little or not at all above the natural ftandard, (as is the cafe in the advanced ftages, of the confluent fmall-pox), our hopes from the exhibition of this powerful remedy would proba- bly be difappointed. But the trial is recommended by every confideration. CHAP. XVIII. Animal Heat—its Origin.—Perfpiration—its cooling in- fluence.—Mode of Operation of other Remedies in Fever —Antimonials—Opium, &c. I HAVE elfewhere obferved, that if a definition of life were required, it might be moft clearly eftablifhed on that capacity, by which the animal preferves its proper heat under the various degrees of temperature of the me- dium in which it lives. The more perfed animals poffcfs this power in a fuperior degree, and to the exercife of their vital fundions this is neceffary. The inferior animals have it in a lower degree, in a degree however fuited to their fundions. In vegetables it feems to exift, but in a degree ftill lower, according to their more limited powers, and humbler deftination. As the capacity of preferving nearly an uniform temperature in all the varieties of climate and feafon, is a criterion of life in the more perfed animals, fo among individuals of the fame fpecies, the degree of this capacity may be confidered as a criterion of the ftrength of the living principle. There is reafon to believe, that while the adual tem- perature of the human body remains unchanged, its health is not permanently interrupted by the variation in the tem- perature of the medium that furrounds it; but that a few degrees of increafe or diminution of the heat of the fyftem, produces difeafes and death. A knowledge therefore of the i85 laws which regulate the vital heat, feems to be the moft important branch of phyfiology. Modern chemiftry affumes to itfelf the difcovery of the origin of animal heat, which is fuppofed to depend on thofe changes in the ingefta, which the fundions of life are always producing. Among the breaching animals, the principal of thefe changes is occafioned by the lungs on the atmofphe- ric air which they inhale, and refpiration is confidered as the pricipal fource of the heat of this clafs of animals. That the oxygen contained in the atmofphere furniihes thelargeft portion of the pabulum of life, is now fcarcely doubted, refpiration being a piocefs in which it paffes from its gafeous to its concrete ftate, giving out a portion of the ^heat it held in vapour, in the fame manner as fleam in its j converfion into water, gives out a portion of its heat. The heat thus extricated, being conveyed by the circulation to all the parts of the body, is the principal means by which j the whole is warmed and animated.* ;: Some phyfiologifts of our own country, and on the ^continent, have of late fuppofed, that a fimilar procefs is carried on by the furface of the body, through which alfo, •though in an inferior degree, the oxygen of the atmofphere :cis inhaled. Experiments are wanting to eftablifh this ipofition, and there is reafon to believe that the principal jfundion of the fkin, in the breathing animals at leaft, is of i;a different and oppofite nature. That an animal pofieffes ; the modern theory of r?l'piration, . v.lich mull be copfeflVd is not without its difficulties. "-4 i86 latent, or to fpeak more philofophically, of reducing ca- loric from a free to a combined ftate, in cafes in which the ftimulus of heat might ocherwife overpower the living energy, there is reafon to believe, from a variety of experi- ments and obfervations. And that this is in part performed by the perfpiration from the furface, can fcarcely admit of a doubt. The procefs of perfpiration which is continually going on from every part of the body, is in this point of view the converfe of that of refpiration: as in refpiration a gas is conftantly converted into a folid or fluid, and thus heat evolved, fo in perfpiration a fluid is continually con- verted into a vapour, anc[ thus heat is abforbed. If then we fuppofe, that while the proportion of oxygen received into the fyftem continues the fame, the temperature of the atmof- phere is increafed, we can underftand why our heat is not increafed by fuppofing an increafe of perfpiration. And if the temperature of the atmofphere remains unchanged, while the oxygen received by the lungs is increafed, we can ftill explain the liability of our heat, by fuppofing an in- creafe of perfpiration. The firft of thefe fuppofitions is nearly realized, when a warm day comes after cold weather; the fecond is realized, when an increafed refpiration takes place under exercife—thus perfpiration appears to have a principal fhare in regulating the animal heat, and the chain of life feems conneded with the phyfical world by two links, which the recent difcoveries in chemiftry enable us to unveil.* * I have faid nearly realized, in the beginning of the fentence. Suppofing the fame bulk of air breathed in warm as in cold weather, the proportion of oxygen will be rather lefs in the firft cafe, from the diminifhed denfity of th« air. There is reafon to believe alio, that an animal contaminates the ail more flowly in warm weather, that is, receives a lefs propoition of theoxygn it inhales, into the fyftem. But thefe particulars, in the rapid and gentral views which I offer, are neceflarily overlooked. Dr. Mitchell, of New-York, in his paper on ihe nature of contagion,hai aflsrted, that the a&ual heat of the animal is always proportioned to ih' quantity of oxygen inhaled; but a very curfory examination of fails will fhew that this is erroneous. By the experiments in Chap. XV. (and various others might be adduced), it will be feen, that the Jiving body Ins the pow« of preferving its heat nearly unchanged for a conliderable length of time in fo denfe a medium as water 50 degrees colder than the blood. This could not arife from an increafed inhalation of oxygen. The phenomenon is pan IJ to be explained from the fudden contraction of the peifpiratory oigan>i but principally, from the powerful impreflion on the fenfation, roufing tl>{ 187 A velTel filled with water, and expofed to the atmof- phere cannot be raifed above 212 deg. of Fahrenheit, by any quantity of fuel, becaufe, as heat is applied from be- low, evaporation carries it off from the furface. Hot fprings are of the fame heat at their fountains throughout the year, probably becaufe the evaporation from the furface of their waters, increafes and diminifhes with the heat of the at- mofphere. In like manner we may fuppofe the heat of the living body to be kept uniform by the evaporation from its furface increafing or diminifhing according to the quantity of heat extricated in the fyftem, or received from the fur- rounding medium. But the cautious reafoner, aware of the deceptions arifing from fuch analogies, will here very properly inquire—Does the perfpiration by the fkin, the body remaining at the temperature of health, actually go on more rapidly in warm than in cold weather? Is it greater under exercife than when at reft? Is it more plen- tiful when oxygen is received in abundance into the fyftem, than when it is imbibed more fparingly ? We run little hazard in anfwering the two firft of thefe queftions in the affirmative, but in regard to the laft, farther experiments are requifite to enable us to decide. The infenfible perfpiration attracted the notice of phyfi- cians very early, and it was a common dogma among the ancients, which has defcended with too little examination to our own times, that the whole furface of the body inhales and exhales. The fubject has been confidered more accu- rately fince the experiments of Sanctorius fn the middle of the laft century ; and the great quantity of matter fuppofed by him to pafs off by this procefs, pointing out its import- ance in the animal economy, theories of difeafe, founded on the diminution or obftruction of this difcharge, have fince his time prevailed univerfally. The quantity of the matter of perfpiration is not eafily afcertained, and this certainty muft continue while the effect of refpiration on the weight of the body remains undetermined. It was for fome time vital principle to increafed exertion, and to increafed extrication of heat. It is to be obferved too, that it was the trunk, and more folid parts cf the body- that preferved their heat, in the experiments refeired to—the extremities be- came cold. i88 believed, that the quantity of perfpiration from the furface had been exaggerated by Sanctorius; but fince a notion has been entertained of the great abforption by the fkin, his calculations have been fuppofed to fall fhort of the truth. If however we calculate that fifty ounces of water are con- verted into vapour on the furface of the body in twenty- four hours, this muft produce a very confiderable abforp- tion of heat, and have a powerful influence on the tempe- rature of the living fyftem; and however we may diflruft the experiments hitherto made, on the quantity of the mat- ter of perfpiration, there is no reafon to queftion the points in which they all agree—that this difcharge is greater in warm weather than in cold—under exercife than when at reft.* Important as the evaporation from the furface of the bo- dy muft be in regulating the heat, it is remarkable how little it has hitherto been confidered in this point of view. In the year 1755, Dr. Cullen publifhed his difcovery of the cold produced by the evaporation of fluids, (Effays and Obfervations, Phyfical and Literary, vol. ii), a phe- nomenon long known in Afia, but till then unobferved in Europe, and which has paved the way to fo many other * Very varidus calculations have been made of the quantity* of mattet peifpired. The only experiments made in this country on this point, tliat deferve much notice, are thofe of Mr. Cruikflianks. He appears to have loft upwards of feven pounds weight in this way in twenty-four hours, when at reft, in an atmofphere of 71 deg. but under exercife, a much laiger quantity. This exceeds the calculation of Sanclorius. 1803. In the report of M. Lavoiffier and M. Seguin, on tranfpiration, (per- fpimi..n), publifhed in the laft volume of the Memoirs of the Academy of Sciences, printed in 1797, this is ftated differently: According to their ex- pel iments, the lofs of weight by perfpiration and lefpiiation which an indivi- dual fuftains in a moderate heat, and who does not undergo much bodily exercife, varies from 11 to 32 grains in the minute, that is, from one pound eleven ounces and four drachms, to five pounds in twenty-fotii hours. The medium may be taken at two pounds thirteen ounces in twenty-four hours, of which one pound fourteen ounces partes off by cutaneous perfpiration, five ounces five drachms and lixty-two giains by puimonary \ erfpiration, and three ounces three drachms and ten grains, by the confumption of carbon in refpiration. Thefum of this lofs is however greatly increafed by exercife, or an increafe in the heat of the atmofphere. Ii is needltfs to add, that the experiments of Lavoiflier and Seguin carry with them the higheft authority, and it is deeply to be lamented that the death of Lavoiflier, and the horrors of the revolution, cut fhort the experimental inquiry they had undertaken into all the principal functions of the human body, in health and in difeafe. 189 difcoveries of the modern chemiftry. It does not how- ever appear, that Dr. Cullen applied his difcovery in ex- plaining the function of perfpiration. The effects of eva- poration from the furface in cooling the body, was how- ever foon after obferved by Dr. Franklin. In a letter, dated June, 1758, is the following obfervation: " Du- " ring the hot Sunday at Philadelphia, in June 1750, " when the thermometer was up at 100 deg. in the fhade, " I fat in my chamber without exercife, only reading and " writing, with no other clothes on than a fhirt and pair " of long linen drawers, the windows all open, and a brifk " wind blowing through the houfe j the fweat ran off the " backs of my hands, and my fhirt was often fo wet as to " induce me to call for dry ones to put on. My body "however neVer grew fo hot as the air, or the inanimate " bodies immerfed in the air."* It does not indeed ap- pear that Dr. Franklin actually meafured his heat, but he makes the inference of his comparative coolnefs from re- membering, that all the bodies about him, even the fhirt but of his drawer, felt warm to the touch, and he con- xludes that he was kept cool " by the continued fweating, r< and by the evaporation of that fweat." Doubtlefs this 'eafoning was fuggefled to Dr. Franklin, and perhaps the whole circumftances recalled to his mind, by the paper of Dr. Cullen, then recently publifhed. When, by the ob- servations of Meff. Du Hamel and Teller in France, and he experiments of Dr. Fordyce and Sir Charles Blagden n England, a difcovery was made of the very extraordi- nary degrees of heat which the living body can fupport, ohilofophical minds naturally endeavoured to account for b fingular a phenomenon. That the animal poffefles a bower of generating cold as well as heat, was the more general opinion : but the conclufivenefs of the experiments if our Englifh philof >phers to eftablifh this opinion was queftioned by many, and among others by my late inge- nious friend Dr. Bell, in the paper that forms the firft lumber in the Memoirs of the Society of Manchefter. In ,:his paper the effects of the evaporation from the furface in * See Franklin's Letters and Papers, p. 365. 190 reducing the heat during the experiments in queftion, is particularly infifted on. In difcuffing this fubject with Dr. Bell, it fuggefted itfelf to me, that the principal office of the infenfible perfpiration might be to regulate the animal heat, and this opinion, which feems fo reafonable, has been confirmed by reflection and obfervation. But whatever njay be the influence of perfpiration in cooling the body, it is not perhaps the only procefs by which this effect is produced. From fome experiments in the hot bath, it appears to me that the temperature of the body is with difficulty increafed after the fweat begins to flow profufely, and as there can be no evaporation from the fkin when the body is immerfed in water, and little from the lungs when the air infpired is already loaded with vapour, fhould my obfervation be confirmed by future ex- perience, it will perhaps fhew, that in the production of fweat itfelf a degree of heat is abforbed, and thus explain in fome degree the reduction of heat that follows profufe perfpiration in other cafes. It was indeed fuppofed by Al- binus, Haller, and William Hunter, that the fweat, as well as the infenfible perfpiration, is an exudation of the watery part of the blood through the cuticle; but this opi- nion is contrary to all analogy, and depending on experi- ments made on the dead body, may be fafely rejected, notwichflanding the illuftrious names that countenance it. The opinion of Dr. Fordyce and Mr. Cruikfhanks feems to be the true one. The matter of perfpiration is fepara- ted from the blood by the capillary arteries, and thrown out on the furface by organic pores in the cuticle, (how- ever difficult to be difcovered), connected with the extre- mities of thefe arteries; and in this procefs there is not a feparation merely, bur a new combination, as in fimilar in- ftances. In this combination there may be an abforption of heat, and thus the coolnefs produced by fweating be in part accounted for. The abforption of heat may howevet take place in various other proceffes, befides the produc- tion and evaporation of perfpirable matter; as doubtlefs its extrication takes place in various other proceffes befides refpiration; and after all, the fudden changes of tempera- ture that take place in certain circumftances, render it I9I probable that the animal poffefies powers over its heat not yet underftood.* Leaving this point for future inquiries, the importance of perfpiration to the animal economy we may fafely af- firm. By this procefs the ftimulus on the extreme veffels, arifing from morbid diftenfion, is diminifhed or removed, and whatever other methods the fyftem may poflefs of di- minifhing its heat, this difcharge feems by far the moft important, and in certain circumftances effential to that object. In fituations where the organs of perfpiration are fpafmodically conftricted, while by the increafed momen- tum of the circulation, heat is preternaturally evolved, (as in the commencement of fever), we can eafily underftand the diforder of the fyftem that enfues. It is obferved, that perfons who engage in exceffive la- bour, fpeedily fink under it, unlefs they perfpire freely, and fupport their perfpiration by drinking fome thin and moderately ftimulating fluid. This is the cafe with the reapers in Pennfylvania, where the harveft occurs in the hotteft feafon of the year, and who, by means of profufe perfpiration, are enabled to work in the funfhine, in which the thermometer rifes very often above the heat of the blood.f This is the cafe with our coal-heavers, who pro- bably lofe a fifth or fixth part of their whole weight by this difcharge daily, and who fupply this wafte chiefly by large draughts of porter. In inftances of fuch extreme labour, a fudden ftoppage of perfpiration from the cefla- tion of exertion, and the acceffion of cold, is frequently fatal, as has already been explained. Europeans who go to the Weft Indies are more healthy in proportion as they perfpire freely, efpecially if they fup- * Vatious ingenious arguments have been ufed by different friends, and correfpondents, to fhew the improbability of an abforption of heat in the formation of the matter of perfpiration ; this being a fuppofition which in- fers, that the matter of perfpiration has a greater capacity for heat than the blood from which it is fecreted, which is contrary to analogy. I have thrown out the fuggeftion, but would not be thought to reft any weight upon it. There are phenomena which occur in the fudden heating and cooling of the living body, which I am far from thinking we can account for by any known chemical principles. f See Franklin's Letters and Papers, p. 336. 192 port the difcharge by a moderate ufe of gently ftimulating liquids, ftopping fhort of intoxication, and guard againft the effects of too exceffive an evaporation when their vi- gour is impaired by fatigue. In the extreme heats of the torrid zone, this indeed is not eafy. The highly excitable fyftem of the youthful European is acted on powerfully by the climate. If the orifices of the fkin do not pour out a proportional quantity of perfpiration, difeafe muft enfue from the direct ftimulus of heat; and if the neceffa- ry quantity of perfpiration takes place, the fyftem is en- feebled by the evacuation, and the extreme veffels lofing their tone, continue to tranfmit the perfpirable matter after the heat is reduced as low as its natural ftandard, or per- haps lower—as occurs in the cold colliquative fweats in the latter ftages of fever. In this fituation we can eafily fuppofe, that even a flight degree of external cold may be- come dangerous. The damps and chillinefs of night, joined to the increafed evaporation produced by the night breeze, muft often prove pernicious, efpecially after exer- cife and profufe fweating. They rob the furface of its ne- ceffary heat, produce a torpor and contraction of the ex- treme veffels, and the dangerous re-action of the centre, which has already been explained. The proper treatment of the European on his landing in the Weft Indies, may probably confift in his being placed for a time in fome in- land and elevated ftation, where the land being cleared, the air is pure, and lefs fultry than on the coaft; on his avoiding as much as poflible any violent exercife; on his guarding againft all intoxicating liquids, and whatever in- creafes the heat and diminifhes the ftrength of the body- taking care however to fupply the circulation with liquids proportional to the wafte. By fuch means his fyftem will gradually accuftom itfelf to the climate, the organs of per- fpiration adapt themfelves to the increafed heat, and the dangers of fudden change be averted.* • 1803. This reafoning would be much ftrengthened if we could rely on an obfervation of Dr. M'Kitterick Adair, quoted by Dr. Rnfh in his Medica! Obfervations and Inquiries, "that the heat of the European on his arrival " in the Weft Indies, has been obferved to be three or four degrees higher " than that of the natives, or of thole accuftomed to the climate, to which. " however it gradually finks in the comfe of time." The experiments made 193 The perfpirable matter of the European does not appear to be well fitted to the torrid zone> Confifting neaily of pure lymph, it is fpeedily diflipated by evaporation, and without a profufe difcharge, the furface cannot be kept moift and cool. On the other hand, the profufion of the difcharge debilitates the fyftem, and renders even the cold of evaporation dangerous, efpecially when this evaporation is increafed by an accidental breeze, or the effect of the cold promoted ^by reft after fatigue. The negro, fitted by nature to the? climate, is lefs acceflible to the ftimulus of heat, and his unctuous fweat lefs eafily diffipated, keeping his fkin uniformly moift, fuftains a more uniform perfpiration, as well as evaporation, and guards the fyftem againft the walk and danger of profufe fweating under fatigue, as well as the other confequences already explained. The pungent and ftimulating quality of his pcnpirable matter will promote thefe falutary effects. In this view of the fubject, it may be worthy of inveftigation, whether the practice of the ancients of ufing unguents on the fkin, ftill general among the eaftern nations, and common among all favages, whofe defective cloathing obliges them to guard by this means againft the viciflitudes of temperature', fhould not be revived by our countrymen in the Weft In- dies. It has been imagined, that thofe unguents effectually obftructed the perfpiration; but this notion has been adopted by Dr. Chifholm, in Demerary, to afcertain this point, contradict, this afTer- tion, and lead us to fuppofe that it is one of thole inconliderate obfervations by which medical fcience is fo often corrupted. In twelve white perfons newly arrived from Great Britain or Ireland, Dr. Chifholm found the mean heat, taken at the arm-pit, 96 degrees. In twelve white perfons whofe period of refidence within the tropics was from 4 to 20 years, the mean heat was 96 deg There was little or no differ- ence when the trial was made on negroes, whether from Africa, or Creoles. Thefe laft however feemed to have the greateft heat, the medium of twelve of them being 98 degrees, nor was there any diffeience in the heat arifing from the period of life j infancy and age being of equal temperature. See Dr. Chifholm s Effay on the Malignant Pefiilential Fever of the Weft Indies. Vol. ii. />. 468. If we could implicitly confide in the experiments mentioned by Dr. C. which give twic- the proportion of oxygen yas to the atmofphere within the tropics which it podefies in Europe, a diffeient direction would be given to our in- quiry refpecting the effects of the Weft India climate on Europeans; but where the refult is fo unexpected and extraordinary, repeated experiments are neceffary to confirm it. 25 194 without inquiry, and againft probability. Thefe unguents, like the perfpirable matter of the negro, may be formed of a confiftence, that while it retards exceffive fweating, does not obftruct moderate and neceffary perfpiration, and being themfelves evaporable, they may keep up a coolnefs that fhall diminifh the neceflity of the natural difcharge. In the warm climates the tepid bath feems a neceffary ad- junct to inunction. It has been for fome time ufed among the French in the Weft Indies, and is no^w (as we are in- formed) beginning to be adopted by the Englifh; and with proper reflections, it may produce the happieft effedts. After exercife under a burning fun, when the ftrength is wafted by fatigue and perfpiration, immerfion in the bath heated from 90 deg. to 95 deg. of Fahrenheit, will be found moft grateful and falutary. It reftrains the profufe and col- liquative fweating ; keeps up the heat of the furface and ex- tremities ; and prevents the dangerous re-action of the cen- tre, which a torpor of the extremities fo generally produces. It allays the violent action of the heart and arteries, and foothes the fyftem of fenfation. On leaving the bath, fric- tion, and inunction of the furface prevent the chill of eva- poration, and while they enfure the fafety of bathing, they prolong the pleafure of this claflic gratification. The re- finement of modern manners has introduced linen tegu- ments next the body, and abolifhed inunctions of the fur- face. Hence the warm bath has become lefs fafe, as opening the pores of the fkin, and expofing the naked body to the chills of evaporation; and thus through the greater part of Europe it no longer forms a part of the regimen of health. In the eaft it ftill prevails. If it fhould be revived among our countrymen in the weft, they muft conjoin with it the inunctions of the furface, and the fine flannel teguments next the fkin, which accompanied its ufe among the Greeks and Romans. In recommending a trial of un- guents to the practitioners of the torrid zone, I may fhelter myfelf under the authority of the celebrated Lord Verulam, unqueftionably the firft phyfician, as well as the firft phi- lofopher and ftatefman of the century in which he lived. " Inunftio ex oleo, et hyeme confert ad fanitatem, per ex- " clufionem frigcris, et aft ate, ad detinendos fpiritus, et !95 u prohibendam exolutionem eorum, et arcendam vim aeris, " qua tunc maxime eft pradatoria. Ante omnia igitur ufum " olei vel oli varum vel amygdali dulcis, ad cut em ab extra " unguendum, ad hngavitalem conducere exiftimamus.*'* The operation of unguents on the furface of the body prefents indeed a fubject for important and original obfep- vation. The effects of the warm and tepid bath, though more inveftigated, are fcarcely better underftood, for per- haps there is no part of medicine on which fo much has been written, and fo little been decided. Thefe fubjects are connected together, and might form, with great ad- vantage, part of an experimental inquiry into the laws of animal heat. The commonly received opinion, that the warm bath relaxes and enfeebles the fyftem, muft, I ap*- prehend, be admitted with many reflections. Immerfed in water, or in air, heated to the degree that quickens the circulation, we are doubtlefs fpeedily enfeebled. But by a heat fhort of this effect, it may be difputed whether de- bility is ever produced. The degree to which the bath muft be heated in order to quicken the circulation, ap- proaches nearly to that of the blood. In my own cafe I have found the pulfe become more frequent at 96 deg. when the ftomach was empty, but at 94 deg. after dinner; and the practice, faid to have been adopted by the ancients, of going into the bath to relieve themfelves from the op- preffion of an overloaded ftomach, would appear to me to have been attended with fome hazard, and with great in- convenience. It does not indeed appear how the defired effect was obtained, except through the means of profufe fweating. In future experiments refpecting the effects of the warm bath, it will be of importance to obferve the heat at which the fenfible perfpiration begins to flow; which probably varies a good deal in different confti- tutions, and which as it varies, will materially affect the refults. It will be important alfo to notice the ftate of the ftomach as to fullnefs; the condition of the pulfe ; the pre<- vious degree of exercife; and the actual heat of the furface; * See Fran. Bacon. Opera fol. Francofurti ad Moenum, 1665, /. 536, 537» 538, where the practice of various nations refpecting unguents is con- fidered at fome length, and the cautions requilite in adopting this practice, left the body fhould be overheated, &c. ate very ingeniouily detailed. 196 all of which, according to my obfervation, will influence the experiments. In all inflammatory difeafes, it is of importance not to ufe the bath heated to the degree that materially quickens the circulation; where this is not attended to, the fymp- toms are heightened, unlefs indeed a fpeedy and profufe perfpiration enfues. In the'degrees in which it does not quicken the circulation, the warm bath is foothing and fedative, efpecially when the immerfion is prolonged ; and it is the temperature from 90 deg. to 95 deg. that is fo An- gularly reftorative after fatigue, though a ftill lower heat is fafe and refrefhing, as thofe who have ufed the baths of Buxton can teftify.—The warm bath is frequently employ. ed to excite a fenfible perfpiration, which may be pro- longed after leaving it; and in this way it may be ufed with great advantage. Where this object is in view, it is advifeable to immerfe the patient in the water heated to 94 deg. or 95 deg, and very gradually and flowly to increafe the heat to 97 deg. or perhaps 98 deg. watching its effects. When the fweat begins to appear on the forehead, if the pulfe remains calm, and the patient feels at eafe, an in- creafe of heat to 99 deg. or even 100 deg. may be ventu- red on with fafety, fhouki profufe perfpiration be required. But when the bath is heated in the firft inftance to 100 deg. the ftimulus of heat generally produces a feverifh circula- tion, which the fubfequenl defective perfpiration cannot allay. The injurious effects are ftill greater where the bath is heated at firft to 105 deg. or upwards, and fweat, in- ftead of flowing more freely in confequence of the in- creafed temperarure, is difcharged with greater difficulty, the ftimulus of the heat, and the fuddennefs of its applica- tion, inducing a contraction of the oiificesof the extreme veffels of the fkin. In this refpect, as in moft others, the analogy is perfect between the ftomach and the furface; for it will uniformly be found, that fweating is excited more eafily by draughts of tepid liquor, than an equal quantity of the fame fluid fwallowed as hot as it can be borne, The fenfible perfpiration excited in the warm bath does not lower the temperature of the body while immerfed, I07 but being prolonged afterwards, it becomes powerfully refringed, and is a remedy of great efficacy. Thefe ob- fervations however fhew the importance of regulating the temperature of the warm bath by the thermometer, and demonltrate how little dependance can be placed on the obfervations of thofe writers who fpeak of its effects with- out noting its temperature. A variation of two or three degrees, often impoflible to be afcertained by the fenfa- tions, will not merely vary the degree, but alter the nature of its effects. The view given of the nature of fever, and of the func- tions of the perfpiration, feems to afford an obvious ex- planation of the operation of thofe antimonial emetics, and fudorifics, by the early exhibition of which fevers are often flopped in their firft ftages. The direct action of thefe medicines on the ftomach refolves the fpafmodic ftricture of the capillaries of that organ and of the furface, by which the morbid heat is confined; while the concuflion given to the whole fyftem diffolves the morbid catenation, and terminates the difeafe. Thofe remedies are however un- certain in their beneficial effects, and always highly debi- litating. They cannot enter into competition with the affufion of cold water on the furface, but may be employ- ed when the prefence of local inflammation precludes the ufe of that powerful remedy. Thefe general views caft fome light alfo on that moft curious fubject, the operation of opium on the living principle. In former times it was difputed whether opium was in its nature cold or hot; in our own days it has been difputed whether it is ftimulant or fedative. Such ab- ftractions afford exercife for the ingenuity, but in the way in which they have been conducted, they foar above utility and truth. Opium relieves pain, and produces fleep, and thefe effects being in general concomitant, may be treated of together. But though opium generally produces fleep, yet we are fometimes difappointed in this effect, and efpe- cially in thofe feverifh diforders where fleep is of fuch high importance. About nine years ago, I attended a boy of ten years of age, the fon of a friend, dangeroufly ill of fever. 198 His nights had been fleeplefs, and the general irritation was very great. Opium had been adminiftered in vain. I determined to give it in larger quantities, and to watch its effects. At ten at night he took forty drops of lauda- num; at twelve the fame dofe was repeated. As I flood by his bed two hours afterwards, he appeared in an im- perfect and agitated fleep: his eyes were half open, his face was livid; his lips and fkin parched ; he was evident- ly much difturbed, and moaned in his breathing. At this time I perceived that he had toffed the clothes off his feet, which lay naked, and that he grafped the cold bed-poft with one of his hands. On examining his hands and feet they felt dry and burning. There was tepid vinegar in the room, and I moiftened firft his hands, and then his feet with it, without awaking him, repeating this practice from time to time: he became more quiet. Thus encouraged, I gradually moiftened his legs and thighs in the fame man- ner, and at length his breaft and neck, and removing the reft of the bed-clothes, left him covered with a fheet only. In a little while the agitation fubfided, and he funk into a found, and feemingly peaceful fleep, which continued feveral hours, the furface of his body being bedewed with a gentle perfpiration. This interefting cafe, pointed out to me clearly, that the fedative effects of opium are often counteracted by the fti- mulus of heat on the furface and extremities, and that the actual ftate of the heat of the patient is a circumftance re- quiring particular attention in the adminiftration of this powerful remedy. The following obfervations are the refult of the inquiry which thefe reflections fuggefted. Opium given in health generally produces fleep, if the mind be vacant, the ftomach empty, and external imprej-, fions be excluded. In this cafe, its firft effect is to increafe fenfibility, to give a gaiety and livelinefs to the imagination, and to diffufe a genial glow over the furface and extre- mities. The actual heat of the trunk of the body is little if at all increafed, but the furface and extremities are brought up to the general temperature, (97 deg. or 98), and a gentle, and as it has been called, a breathing per- i99 fpiration is diffufed over the fkin. In this ftate we fink into thofe happy flumbers which are ill exchanged for the reali- ties of life. On the approach of fleep, the pulfe is gene- rally increafed in frequency by four or five pulfations in the minute, and the refpiration is flightly irregular, as in the gentler degrees of pleafurable emotion ; but as the fleep becomes fixed and profound, the pulfe fubfides to its loweft and moft tranquil ftate, and the refpiration becomes regu- lar, deep, and rather flower than natural. The various circumftances that prevent this favourable operation of opium, even in the ftate of health, it is not our purpofe to confider at prefent. When opium is given in fever, if the heat be two or three degrees or upwards above the natural ftandard, and the fkin dry, it feems very generally to increafe the heat and reftleffnefs. There are exceptions. If the heat, though preternaturally great, is fubfiding, and the fkin beginning ! to foften, though not yet moift, opium very often accele- rates the perfpiration, and by this means dimlnifhes the -heat. In fuch cafes its falutary effects, tranquility and :fleep, generally follow. Thus it will happen, that an -anodyne draught glyen early in the evening, fhall occafion -increafed heat and agitation, which if deferred till two or three in the morning, would have produced fenfible per- spiration and repofe. In the evening the exacerbation of ^ fever is on the increafe, or at its height, which towards £;,.morning is fubfiding, the difference in the actual heat of ...the furface being often not lefs then two degrees or up- wards. A dofe of opium given in the hot ftage of inter- mittent fever, will often accelerate the fweating ftage and ,fhorten the paroxyfm, which under fimilar circumftances in continued fever, has a contrary effect; becaufe in the $ former cafe the difpofition to perfpire is more eafily excited. ;But even in intermittent fever, opium when given in the o-hot ftage, will be much promoted in its diaphoretic and : lalutiiry effects, by moderate draughts of tepid, or if the «l heat be great, of cold liquids. In continued fever, where the heat is great, and the fkin dry, it is proper to lower ■ the temperature of the furface, and if poflible to excite lyfenfible perfpiration before opium is adminiftered, if we 20O wifh to enfure its diaphoretic and foporific effects. But even after opium has been exhibited, when inordinate heat prevents its fedative operation, it will be found fafe and falutary to ufe the tepid or cold affufion ; and when the heat is by this means reduced, repoie and fleep will follow. Tepid or cold drink will produce, though in a weaker de- aree, fimilar benefit. Thefe methods of promoting the diaphoretic effects of opium, feem more certain and ad- vantageous in fever, than the practice of combining it with ipecacuanha, or the preparations of antimony ; but where opium is to be ufed in inflammatory difeafes, or in dyfen- ■ tery, doubtlefs this laft method is to be preferred. Thefe j remarks muft be confidered as applying to opium in its , ordinary doles, that is, from half a grain, to two or three j grains of the extract, or from ten to fixty drops of the Tincture. Perhaps it has been too much the practice of late | to give this medicine in large dofes, and to overlook its , effects in fmaller quantities. Experience has convinced me, that confiderable effects are produced on the fyftem by a very few drops of the tincture properly adminiftered, and that it is always unwife to employ it in dofes larger than neceffary to produce the defired effect. The effeds of alcohol (under which term I comprehend the fpirituous and vinous liquors) on the fyftem, have a ftriking refemblance to thofe of opium. Alcohol is more heating, lefs diaphoretic, and lefs foporific. When how- ever the mind is vacant, the ftomach empty, and external impreffions excluded, alcohol like opium has a tendency to induce fleep. As fleep however approaches, the heat of the body rifes, efpecially on the furface and extremities, and ftimulating the heart and arteries to increafed action, produces a ftate of agitation with which fleep is often in- compatible. Or if the dofe has been fucn as to benumb the fenfes, with the firft return of fenfibility, the drunkard is roufed by intolerable heat from his apoplectic flumbers. The degree of heat in the fever of intoxication is douDtlcfs various in various conftitutions. I have obferved it to rile to 105 deg, nearly the higheft degree of heat in the typhu* of this ifland ; and Dr. Alexander in his own cafe found it as high as 107 deg.—Under thefe degrees of heat, the 201 thirft, agitation, and confequent debility, are very confi- derable, the fkin being in general obftinately conflicted. The proper treatment in this, as perhaps in all other cafes of morbid heat and dry fkin, when local inflammation is abfent, is to pour large draughts of cold water into the ftomach, or to affufe it on the furface. By this practice the heat is reduced, the orifices of the fkin opened, fenfible perfpiration is produced, and or.e half of the mifchief of intoxication is prevented. Similar effects may be produ- ced, though in a weaker degree, by tepid drinks or the tepid affufion.* * 1803. Th* following narrative, which was communicated to me as il- luftrative of thefe obfervations, 1 give in the wurd.,, and on the refpeclable authority of Dr. Robeitfon, late Surgeon-geneial of the naval holpital in Barbadoes. " A Gentleman of this ifland, whofe name was Weeks, a great votary of " Bacchus, was in the practice, from fifteen to twenty years, of plunging in- " to cold water when he rofe from his bottle, and of actually gome to fleep " in a trough full of water, with his heed fupporteel on a kind of wooden " pillow made for the purpofe, above the furface. When he dined abroad, '* and had not the convenience of his own tiough, he ufed to ftrip off his " coat, waiftcoat, and fhirt, and fit expoied in the open air, and in that fitu- " ation go to fleep, whether it rained or not. And fometimes he went and '• bathed in the neareft adjoining pond, to which he generally required aflift- " ance to be conveyed. The effect of this practice was, that inftead of ex- periencing debility, lafiitude, head-ache, and naofea, he found himfelf on " awaking, cheerful and refrefhed, and free from all the effects of intoxica- " tion. l,i the year 1789, dining one day abroad, he got alternately drunk " and fober three feveral times before midnight, each time recovering his fo- " briety by immtrfing himfelf, and fleeping in cold water j and on awakening •• returning to the company. The lalt time, after ftipper, he was fo immo- " deratcly intoxicated, that he infifted on his companions undreffing him and " carrying him themfelves to the pond. They carried him accordingly in *' a chair, and fet him up to the chin in water, where he continued upwards " of an hour, a perfon fuppoiting him. I had this laft circumftance from a " gentleman one of the party, whofe veracity may be entirely depended on, " At home however he ufed, as I have already mentioned, a trough made *' for the purpofe, with a bench in it as a pillow, having been nearly " drowned when fleeping in his pond, from the negro who was appointed to " watch him having himfelf fallen afleep. In th's watery bed he would " fleep, one, two, three, or even more hours, experiencing always the grtateft " refielhment. His wife and family, when they wifhed him to change his '* quarters, ufed to draw out the plug, and let the water run off, when he '< awoke, and humouroufly complained of the lofs of his bed-clothes. At " length this expedient began to lofe its effect in roufing him, and one time, " he continued to fleep in his empty trough. In confequence of this he was " feized with extreme rigors and chills, followed by a fevere attack of rheu- " matifm, which affected him a long time, and made him defilt from the prac- " tice in future. But to the end of his life he was in the habit of fitting, 26 202 The adminiftration of alcohol in fever requires the fame precautions as that of opium. It fhould not be given when the heat is great, and the fkin dry and burning: but it may in general be given with fafety and advantage, when the heat is nearly of the natural ftandard ; and even when '« when intoxicated, with his clothes open, and fometimes quite naked, expo- " fed to the wind and rain. This extraordinary character died of apoplexy " about thiee weeks ago, aged ^xty-three/' ExtraS of a letter fr^m Dr. Robertfon, dated Barbadoes, 4th March 1801. Dr. Robertfon had mentioned to me generally the circumftances above rela- ted, in conveifation, about a year before, and at my requeft piomifed to in- veftigate the particulars on his return to Barbadoes. The above is the refult. Mr. Weeks was alive many months after Dr. R's. return, and this narrative of his practice may be entirely depended on. It would afford room for many obfervations. I fhall offer one or two. Should any one be defirous of following Mr. W's. practice, he muft re- colled, that the cold water of Barbadoes is from 76 deg. to 80 deg, little inferior in temperature to the Buxton Bath. The fuperior coolnefs derived from immerfion in water of this temperature, to that in air of the fame heat, arifes from the greater fpecific gravity of the water, and its much greater power of conducting heat. An attention to this circumftance might be of the utmoft advantage, not merely in difeafes of increafed temperature, but when the living fyftem, though Janguifhing under exceffive heat in the fultry regions of the earth, may be ftill confidered as free from difeafe. We learn from Dr. Chifholm, who ferved with the Biitifh army in South Carolina and Georgia, in the Ameiican war, that in the inland part of thefe countries, whe*re the atmofphere ftagnates during the latter end of fummer, and the heat rifes to 90 deg. and upwards, the inhabitants often take refuge from the in- tolerable oppreffion of the air, by immeifing themfelves in water. This practice ought to be known to our countrymen in the Eaft Indies. I liftened with very painful fenfations to the account of the fufterings and death of an officer of great merit and high connexions, who, when recovering from an illnefs, feems to have funk under the exceffive heat of a ftagnating atmofphere in that country. .An attempt was made to relieve him, by pouring water on a bundle of wet hay in his chamber ; but in a ftagnating ftate of the air, the degree of coolnefs thus produced would be unequal to the object. Had he been immerfed in the water, or had the water been poured over his body, and the air, by artificial means, been made to blow over him when wet, the relief would in ail probability have been effectual. Of thefe two methods, the firft, where the perfon is feeble, is the fafeft, and leaft exhaufting. As a cooling procefs, within the higher degrees of heat to which the atmofphere rifes, the laft is the moft effectual; but the cooling power of evaporation may be carried too far, and requires fkilful management. Dr. Chifholm allures me, that, in the Weft Indies, he has known the heat of the atmofphere fuddenly reduced by evaporation, forty degrees. A confideration of this circumftanee will explain why Mr. Weeks fuffered when the water was drawn off from his trough, and he lay wet and naked, expofed to the wind. Suppofing the water and the air to have been of the fame temperature, the greater denfity of the former was more than compen- sated by the effects of evaporation $ fomething may alfo be imputed to th« etiange of medium itfelf, as explained chap. xv. 203 it is fomewhat above it, if the orifices of the fkin are open, and the furface is moift. Opium, as was before remarked, is more fudorific than alcohol, and given in that ftage of the fever of intoxication in which the fkin begins to relax, it often accelerates fenfible perfpiration, and fometimes oc- cafions it, when it might not otherwife have taken place. In this way I explain a phenomenon which has occurred to others as well as to me, that a moderate dofe of opium fometimes gives extraordinary relief to the drunkard, under the fufferings through which he muft pafs to fanity and ftrength. Thefe obfervations are not offered to the reader as inclu- ding a complete view of the fubject of which they treat. My principal object has been to eftablifh the ufe of a new and powerful remedy in fever, and the general remarks and reafonings which are added, are chiefly with a view to explain its operation and enforce its fafety. As however thefe additional obfervations are on fubjects of great im- portance, it is my intention at fome future period to refume them. In the mean time, it may be objected, that in this rapid fketch, affertions are fometimes given inftead of ex- periments and proofs. In fuch cafes however, it will be found, that the points at iffue may be readily brought to the teft of experiment; and as general and obfcure expref- fions are every where avoided, it will be eafy to refort to this trial; a circumftance which will procure from candid minds a patient hearing, as well as forgivenefs for thofe errors into which I may have fallen. I have only to add, that the application of cold under any form, where fever is combined with local inflamma- tion, is a fubject of much difficulty, and my obfervations upon it muft wait for the elucidations of future experience/* * 1798. Finding that fome of my correfpondents are difpofed to extend the affufion of cold water to fymptomatic and inflammatory fevers, and that they are even inclined to think, that in fuch affections it muft act with pecu- liar advantage, I fubjoin to this third edition, a few obfervations on this point, but rather with the view of inculcating caution, than the hope of directing practice. That the action of cold on the living body is under certain circumftances ftimulating, is maintained in note, p. 67, to which the reader is referred j and this ftimulation depends on the fenfation by which the application of cold 204 For the fame reafon I have avoided a particular examina- tion of the action of cold on the body in health, whether as a ftrengthening or a debilitating power, an inquiry that ought to be firft entered into, in a regular inveftigation of the effects or temperature, and its changes, upon life. is attended. In fever with local inflammation, there is a morbid degree of heat, for which the application of cold would feem the natural practice. But in fuch dilenfes the fenfibility to cold (as well as to othtti powers that ftimu. late) is alfo much increafed, and hence the difficulty of lefoiting to it as a remedy. Cold acting powerfully on the fenfations, will in the firft inltance ftimulate the fyftem ; and it appears to me probable, that in proportion to this ftimulation, is the difficulty of reducing the actual temperature. Hence it may happen, that the injudicious application of cold in inflammatory dif- eafes, fhall increafe the action of the heart and arteries by the ftimul is of fenfation, without fubtracting permanently the ftimulus of inordinate heat. This obfervation extends to meafles, caianh, &c. in which a fenfe of culd is fo eafily excited. To apply cold with fuccefs in inflammatory difeafes, it feems to me pro- bable, that the fenfation which attends it fhould be as much as poflible mode- rated, and that the application fhould be fo regulated as to enfure the effec- tual reduction of the temperature of the patient. If this be the cafe, the fud- den and temporary affufion of cold water, fo advantageous in typhus, will not be falutary, or indeed fafe, in inflammatory fever, in which it appears to me that the patient, if cold is employed, fhould fink himfelf (lowly in the cold bath, continuing the immerfion for fuch a duration as the ftate of hit heat, and of the puliation of his heart and arteries will admit. By the ex- periments in chap. xv. it appears, that under continued immeifion in cold wa- ter, the fenfation of cold fpeedily abates, and that the frequency of the pulfe is in a moft ftriking and uniform manner reduced. And though the heat in the trunk of the body is wonderfully fuftained, yet in the extremities, and over the furface, it is fpeedily and permanently leffened.. It is true thefeef- fects may be modified by difeafe, in fuch a way as to contradict experiment! made on a perfon in health; and though in pine fynocha, the cold bath would probably be advantageous, yet ferious objections m3y prefent themfelvesa- gainft employing it in pleuiitis or peripneumonia; objections which I do not think infurmountable, but which experience neither enables mc to invalidate or to ftrengthen. in pinenitis, gaftritin, enteritis, &c. efpecially in theit defperate forms, I think immerfion in the cold bath ought to be hazarded. It may ferve to fupport this reafoning, that the local application of cold lo parts inflamed, is regulated by the principles I have laid down It muft not be fudden and temporary, but great in degree, and permanent in duration, Iknce the fuccefs with which ce, and fnow, and the clay-cap, are applied to different parts, for the purpofe of preventing or reducing inflammation. In all fuch cafes the fenfation ot cold fpeedily iublides, and even though ice he lying on the part affected. It is well known that the general action of cold may be extended over the fyftem by its application to a part. The ufe of cold in hemorrhages is often regulated by this maxim. I have found that hemorrhagy from the lungs may be flopped by immerfing the feet in cold water, and perhaps this may be done ftill more certainly by a permanent application of cold to the penis and fcroiuflii which part with their heat more eafily than any other portion of the furface 205 CHAP. XIX. Is there an Inhalation by the Skin ?—Cafe of P. M. Esq. who died of Inanition.—General Reflexions. IN fpeaking of the origin of animal heat, and of the na- ture and office of perfpiration, (p. 185^, it was quef- tioned, whether the inhalation of vapour or water through the fkin into the circulating fluids, be eftablifhed by a fuf- ficient induction of facts, and if it occur at all, it was fup- pofed that the quantity inhaled had been much exaggera- ted. Among the ancients, however, the doctrine in queftion was univerfally received, and it has been admit- ted by the moft celebrated phyfiologifts, not merely of the pad, but of the prefent times. The facts and arguments in fupport of it are detailed by Haller in the 5th volume of the Element a Phyfiologia-, but on examination, they will be found to afford no direct proof of its truth.* Of the great variety of authors quoted on this occafion, no one indeed affirms the actual increafe of the weight of the bo- dy in the warm bath, Deffault excepted, and this is a point that Haller himfelf feems never to have fubjected to expe- riment. of the body. I have found that a ftill more powerful effect was produced in hemoptoe, by immerfing the body up to the pubes in cold water, a practice that 1 can fpeak of from experience as often fafe and efficacious in this dif- eafe. But in all thefe inftances, a permanent, as well as powerful applica- tion of cold was requifite, and from the analogy between hemorrhages and inflammations, this may fupport our reafonings refpecting the proper method of employing cold as a remedy , my attention was drawn to the valuable memoir on this fubject read before the Academy of Sciences by M. Se- guin, of which fome account is given by Fourcroy, in the third volume of " La Medicine alaireepar les Sciencesphy- fiques, p. 232." The conclufions of M. Seguin correfpond in every particular with thofe which I have already laid down, and being founded on a great variety of experi- ments made for the exprefs purpofe of determining on the cutaneous abforption, they appear to me to give his in- ferences all the folidity of truth. The objection, that though there is no increafe of weight in the bath, there may be an abforption, which is countervailed by the ex- halation, M. Seguin found a fatisfactory mode of invali- dating. Hediffolved in the water of the bath in which he made his experiments, fubftances which produce a fpecific effect when received into the fyftem, by which their inha- lation might be afcertained. He employed the oxygenated muriat of mercury in folution, on a number of venerial patients, and while the epidermis was entire, he never per- ceived a fingle inftance of falivation, or even of amend- ment of their complaints. But in cafes where a confiderable portion of epidermis was injured or deftroyed, as in the itch, the fpecific effects of mercury on the fyftem were produced. The experiments of Mr. Seguin are very nu- merous, and appear to be devifed fo as to meet every ob- jection. He concludes from the whole, that while the epidermis is entire, the abforbents of the furface take up neither water nor air, nor any fubftance diffufed or diffol- ved in either. &c. under the third. I am not ignorant of the experiments of Dr. Falconer and JMr. Albernethy, nor warning in due refpecl to thofe gentlemen; but my own obfervations, fupported by the experiments of M. Seguin, induce me to reject their conclufions. A probable fource of error in the experimenti fuppofed to aftord a direcl proof oi cutaneous abforption, is, that they were made on a fmall part of the body, e. g. the arm or leg, and not on the whole; though if the mouth aiid noftrils were left free for refpiration, it would be as eafy, and much moie corrtft, to nioke expeiiments for this purpofe, 3a well as for determining the quantity of exhalation, on the whole fin face, ai on a part. Dr. Marcaid, who wrote txpieflly on the efftcls of the bath, ha! adopted the theory of abforption through the fkin, without making any ex- periments. 219 Admitting that the inference of the friend and coadju- tor of Lavoifier are juft, how are we to explain the refrefh- ment and abatement of thirft, experienced by Mr. M. in the bath. Referring to what is faid in pages 132, &c on the nature of thirft, we may here fhortly obferve, that as li- quids thrown into the ftomach relax the exhalents of the fur- face, fo doubtlefs this action is reciprocal; and that the exha- lents of the furface being relaxed in the warm bath, a re- laxation in thofe of the ftomach enfues, by which the fenfe of thirft is abated. In the cold, as well as in the hot ftate of intermittent fever, the thirft is great; but it is always leffened, and generally removed, on the acceffion of the fweating ftage, though no liquid lhould have been fwal- lowed. Will this explanation, it may be afked, account for the benefit derived in accidents at fea, from immerfingthe body in water, or applying wet fubftances to its furface, when no drink can be procured ? it will explain it in part perhaps, but not wholly.—In the torrid zone, where the greater part of thefe inftances have occurred, the immerfion of the body in water, or the application of wet clothes to the fkin, will keep the furface cool, by defending it againft the direct rays of the fun, and thus prevent the debility produced by an accelerated circulation; it will alfo defend it; in whatever climate, from the wafting of evaporation, and thus be a means of prolonging the ftrength. This rea- foning is fupported by a fact which may be inferred from the circumftances I have mentioned, and which is efta- blifhed by the experiments of M. Seguin, that the body wattes much lefs in water than in air. In the Buxton bath I found my weight very flightly diminifhed; but in the cafe of Mr. M. and in all our ex- periments on diabetic patients, there was neither dimi- nution nor increafe in the bath. In the experiments of M. Seguin, there was always fome diminution in the bath, of whatever temperature, which he afcribes to the pulmo- nary perfpiration. How is this difference accounted for? Though the cutaneous exhalation may have been flopped in Mr. M. during immerfion, yet allowing the perfpiration 220 by the lungs to have gone on, this alone, fuppofing no abforption, ought to have produced a diminution of weight in the bath. To this it may be replied, that though no abforption through the fkin takes place in the bath, that by the lungs goes on, while in the heat of 96 deg. the eva- poration from the furface of the water, by loading with moifture the air inhaled, prevents its taking up the moif- ture in the Jungs, and thus diminifhes the pulmonary per- fpiration.—Againft this fource of error it is probable that M. Seguin guarded. It is in this way that the increafe of the weight of the body in moift air, which is faid fome- times to occur, and which has been fuppofed to prove a cutaneous abforption, may be accounted for. In moift air the abforption of the lungs from the atmofphere goes on unchanged, while the pulmonary, as well as the cutaneous perfpiration, is diminifhed, and thus the increafed heat of the body may be explained. On this point however more accurate experiments are required. It was obferved, that the difcharge by urine alone, in the cafe of Mr. M. exceeded much in weight the wafte of his whole body; and it cannot be doubted that the difcharge by ftool and perfpiration exceeded the weight of the clyfters. Thus it appears that the egefta exceeded the ingefta, in a proportion much greater than the wafte of his body will explain. How, it may be faid, is this accounted for, unlefs by cutaneous abforption ? In the fame way, it may be an- fwered, by the action of the lungs. That the oxygen inhaled in refpiration from the atmof- phere, unites in part with the carbon of the blood, to form carbonic acid gas, and in part with the hydrogen, to form water, is generally admitted. In inftances of inanition, we may fuppofe the proportion in which it unites to thefe dif- ferent fubftances to be varied by the compenfating powers of life; that the formation of water is greater than ufual, and that of carbonic acid gas lefs. Thus a portion of the oxygen, which in the ordinary courfe of things is exhaled in the form of an elaftic vapour, being abforbed in the form of water, will ferve to retard the wafte of the body, and to furnifh the blood with the proportion of lymph, which af- 221 fords a proper fupply to the fecretions of urine and perfpira- tion. In the cafe 6f Mr. M. there was no appearance of that acrimony of the fluids which might naturally have been expected from the ceffation of the fupply of chyle, and which Haller defcribes as the conftant effect of inanition. This theory of the increafed formation of water in the lungs has been employed by Dr. Rutherford of Edinburgh, to account for the vaft difcharge by the bladder in diabetes. It feems alfo to account for-the phenomenon of the egefta exceeding the ingefh, fo obferved in that difeafe. It illuf- trates the doctrine of Seguin in the memoir already quoted, of which Fourcroy gives an account in the following words —Le diabete ne provient point de V eau abforbee dans I' air par la peau, mais du reflux de celle qui ne peut pas etre en- levee aux poumons par I' air trop charge d'humidite—a doctrine which appears to be defective, from not pointing out the fource of the increafed quantity of water in the lungs. Beautiful as the theory of Dr. Rutherford is, it cannot be confidered as eftablifhed in diabetes, or in inanition, (to which I have extended it), till the air expired by patients under thefe difeafes fhall be examined. In the mean time I may obferve, that the application of it to the cafe of Mr. M. accords with the ufual economy of the living principle, which, in remedying the defect of particular organs, does not transfer their powers entire to other parts of the fyftem, but modifies or increafes the natural action of fome other organ, by which that deficiency may be to a certain degree countervailed. Such an exertion of the living principle was evident in the increafed powers of the rectum, which have already been defcribed. Thefe vicarious actions of the fyftem are however defective, whether arifing fpontaneoufly, or from the afliftance of art. No applications of food to the inner furface of the rectum can long fupply the abfence of food in the ftomach, nor can the want of liquid in that or- gan be long countervailed by applications of moifture to the furface, aided by the modified action of the lungs. Af- ter a certain time, though immerfed in water to the chin, the thirft will prove intolerable without drink, as the fhip- wreck defcribed in chap. xv. will teftify; and the fuffer- * 222 mos of Tantalus,* which the theories of Dr. Marcard led him to deride, will be rated as highly •by the naturalift as by the poet. The opinion given in the preceding pages having occa- fioned confiderable difcuflion, I think it right to give an abftract from the report of M. Fourcioy, on the Memoir of M. Seguin, not having been able to procure the Memoir itfelf. M. Fourcroy begins with mentioning the circumftances which led M. Seguin to doubt the commonly received opi- nion, refpecting cutaneous abforption, and to make new experiments on the fubject. The Memoir read by him contains the refult. " Nous n'entrerons point," says M. Fourcroy, « dans le detail des nombreuses experiences qui y sont consignees, et que Ton af- foibliroit par la rapidite necessaire dans un rapport •, nous nous contenterons de rappeller a l'Academie les principaux resultats qu'elles ont donnes. Le premier resultat tire de trente-trois ex- periences faites sur lui-meme, c'est que le corps n'augmente pas de poids dans le bain, qu'il perd moins dans I'eau que dans l'air, et que cette perte suit sur-tout la raison de la temperature de l'eau du bain; que la perte de poids dans l'eau a dix ou douze degres (barometre a vingt-huit pouces), est a eelle dans l'air comme 6. 5 est a 17; qu'a quinze a. dix-huit degres de temperature, cette perte dans l'eau est a celle dans l'air comme 7, 5 est a 21, 7; que dans l'eau chaude a virigt six ou vingt-huit degres, elle est a cell* dans l'air comme 13 est a 23. Deux autres personnes ont offett des resultats differens dans ces pertes relatives, mais elles ont tou- jours moins perdu dans l'eau que dans l'air. M. Seguin attribue * Dr. Marcard, in the work quoted p. 139, after aflerting the great in- halation of water by the (kin in the bath, declares, that no naturalift will eftimate the fufferings of Tantalus highly. It feems probable, that immer- fion in tepid water is more effeft ual in abating thirft, than immerfion in cold water. The account I have given of Dr. Rutherford's theory of diabetes, I deriw from the valuable inaugural differtation of Dr. Marcet of London, prefented to me by the ingenious author. The explanation offered by Dr. Marcet of the increafed heat in diabettij will be found I believe irrelevant.—In (even cafes of this difeafe which I h»« examined, the heat previous to the medical treatment was lefs, not greattr than natural, notwithstanding the almoft unanimous concurrence of authori in the contrary ftatement; a proof among many others of the inaccuracy of tin Accounts we have of temperature in difeafe. 223 cette perte moindre a ce que la matiere de la transpiration insen- sible n'est point exposee au contact de l'air qui doit la dissoudre dans l'etat ordinaire. II rend raison de la difference de ces pertes a diverses temperatures de l'air de la maniere suivante. La perte de poids qu'on eprouve dans l'eau a dix ou douze degres, est beau- coup plus foible que celle qui a lieu dans l'air, parce qu'il n'y a point de transpiration cutanee; il n'existe alors que la transpiration pulmonaire: celle qui se fait dans l'eau a dix-huit degres est un peu plus foible que la seule transpiration pulmonaire, parce qu'outre qu'il n'y a point de transpiration cutanee dans ce cas comme dans le precedent, l'air qui entre dans le poumon est charge d'humidite, et ne dissout pas toute celle qui se degage de viscere; enfin, la perte de poids qu'on fait dans un bain d'eau a vingt-huit degres est plus considerable que celle qui est produite par la seule transpira- tion pulmonaire dans l'air a cette meme temperature, parce qu'alors le corps perd, et par cette dernier e"transpiration, et par la sueur qui sort des vaisseaux exhales, en raison de 1'augmentation de i mouvement du coeur et de* arteres, qui, comme M. Seguin l'a ; prouve dans son memoire soffda transpiration, est la seule cause de ! la transpiration sensible, oucfe la sueur. Mais, malgre la diffi?- : rence de ces trois resultats qui dependent de la temperature de l'eau du bain, il n'est pas moins certain qu'il n'y a point augmen- 1 tation du poids du corps par le bain, et qu'il y a seulement une perte moins forte que dans l'air, dependante de l'absence de celui- ci et de la privation de sa qualite dissolvante par rapport a la ma- tiere de la transpiration. " Les premieres experiences dont nous venons d'exposer les re- i sultats generaux les plus importans, prouvoient bien que le corps : n'augmente pas de poids dans le bain, mais elles ne decidoient point encore l'absorption ou la non absorption par la peau, car on pouvoit objedter a leur auteur que la perte moindre que dans l'air dependoit de la portion d'eau absorbee par les vaisseaux inhalans. M. Seguin a pense que, pour repondre a cette objection, il falloit faire baigner des individus dans des dissolutions de substances dont les effets sur 1'economie animale fussent bien tranchans. II a em- ploye la dissolution de muriate oxigene de mercure, a des doses connues, en pcdiluves, sur plusieurs malades attaques de symp- tomes ven jriens, et il a constamment observe que lorsque la peau etoit bien saine, et l'epiderme bien entier, il ne passoit pas de sub- lime corrosif dans leurs humeurs, ils n'eprouvoient aucun des ac- cidens dus a ce sel, et aucune amelioration dans leurs maladies, tandis que dans le cas ou l'epiderme etoit affecte et entame, comme dans la gale, &c. ce sel penetroit le corps et produisoit alors les effets qui qui en font reconnoitre l'existence dans l'economie ani- male. 224 " Non content de ces experiences faites dans un hopital sur plusieurs individus malades, M. Seguin a cru devoir les reconi- mencer sur un sujet sain, les suivre avec une scrupuleuse exacti- tude, jusqu'a ce qu'il eut leve tous les doutes, et il s'est choisi lui- meme pour sujet de ces nouvelles tentatives. En tenant a un grand nombre de reprises differentes, pendant long-temps a chaque fois, une partie de son bras plongee dans une dissolution connue de sublime corrosif a differentes temperatures, et disposte dans un manchon de verre recouvert de taffetas gomme, de maniere a ce qu'il n'y eut point d'evaporation sensible, le reste de son corps, excepte sa boucne, etant d'ailieurs enferm- dans l'enveloppe im- permeable de taffetas cire, afin de pouvoir appr^cier la transpire tion pulmonaire comme il avoit apprecie la perte dans l'air de la partie du bras plong e dans la dissolution, M. Seguin est parvenu a obtenir des rcsultats aussi singuliers que nouveaux: nous nerap- porterons ici que ceux qui out trait a 1' absorption par la peau. Quand la dissolution de devrx gros de sublinu dans dix livres d'eau est a dix et a vingt-huit degres de temperature, la quantite de ce sel dans le bain est tres sensiblemen^la meme apres 1'expe.rience ! qu'auparavant, et cons^quemment il'n'y en a pas d'absorb.; mais i dans la meme dissolution a dix-huit degres, si la presque totality du bras tres-sain, et dont l'epiderme est bien entier, y reste plon- gee, il y a par heure 1, 2 grains de sublime absorbe, quoique l'eau du bain qui tenoit cette portion de sublime en dissolution ne soit point elle-meme absorbee. M. Seguin tire de ce singulier resultat [/in- duction que ce n'est pas par les vaisseaux lymphatiques que ce fait cette absorption du sublime, car ces vaisseaux absorberoient bien plus facilement l'eau, qui cependant n'eprouve pas de diminution, mais par les vaisseaux exhalans. L'auteur explique ce ph/nomene d'une maniere tres-ing^nieuse: il pense que ces vaisseaux exhalans ressenvs par des temperatures basses telles que douze, en cvacu- ant des gouttelettes de sueur continuelles par un effort plus consi- derable du coeur et des arteres produit par la temperature de vingt- huit degres, et n'absorbant cons'quemment aucune parcelle de sublime dans les deux circonstances, se trouvent tellement disposes a la temp:rature de dix-huit degris, que suffisament dilates pour que l'eau de la dissolution soit en simple contact a leur extremite avec l'humeur transpiratoire, sans etre repoussee par l'ecoulement de cette humeur, comme cela a lieu a vingt-huit degr.s; alors ce contact sans mouvement permet a l'humeur de la transpiration de dissoudre de proche en proche une partie du muriate oxig ne de mercure dissout dans le bain, de le partager avec sa premiere eau de dissolution, de se mettre avec elle dans un veritable .'tat d'. quili* bre, comme cela a lieu dans toutes les dissolution salines meUes avec de l'eau pure. Ainsi, suivant lui, une dissolution saline a 225 dix ou a vingt-huit degres etant mise en contact avec la peau hu- maine bien saine, il n'y a point d'absorption ni de la part de l'eau ni de la parte du sel; la meme dissolution a dix-huit degres, mise en contact avec la peau qui ne transpire point dans l'eau a cette temperature, permet a l'humeur de la transpiration de partager Le sel de la dissolution jusqu'a l'equilibre de saturation et de le porter dans la circulation : cet effet n'a pas lieu lorsque les pores des vais- seaux exhalans sont resserres par une temperature basse ou traverses par les courans de sueur qui repoussent la dissolution de sel. Les vaisseaux lymphatiques n'enlevent ni solide, ni liquide, ni fluide elastique a la surface du corps; les vaisseaux exhalans n'absorbent jamais ni solide insoluble, ni liquide, ni gaz, parce qu'ils sont tou- jours pleins de la liqueur transpirable. L'absorption qui n'a lieu que dans une certaine temperature, et qui tient a la tendance a l'equilibre entre un liquide non sature et un liquide sature, est par cela meme tres bornee. " M. Seguin, en poursuivant la description de ses experiences, confirme les assertions precedentes, par l'histoire de plusieurs ma- lades veneriens, chez lesquels la dissolutions de sublime employee en lotion n'a rien fait tant que l'epiderme n'a point ete entame; d'autres a qui le sublime ainsi que le muriate d'ammoniaque et de mercure ou le sel alembroth, appliques a sec, n'ont produit d'effets que lorsque la peau s'entamoit par l'acrete de ces sels; de quelques- uns qui n'ont eprouve ni erosion, ni action consequemment du muriate de mercure ou mercure doux applique sur la peau. Le tartrite d'antimoine et de potasse ou le tartre stibie, applique ainsi sur le ventre, a purge apres avoir produit des boutons dans le lieu de l'application ; la gomme gutte, scammonee, appliquees sur le ventre a. sec, et recouvertes comme les matieres pr cedentes d'un emplatre agglutinatif a sa circonference, n'ont fait naitre aucun effet sensible. L'onguent mereuriel n'agit que par une friction qui fait p '-n ,'trer 1'oxide de mercure sous l'epiderme, et le met dans le cas d'etre absorb..'; un onguent fait avec le sublim' corrosif entame la peau, et devient un des moyens les plus prompts et les plus adtifs de faire penetrer du mercure tres-oxide dans le torrent de la cir- culation. "II n'est pas mcessaire d'entrer ici dans de plus grands d tails sur les experiences tres nombreuses de M. Seguin, pour faire con- cevoir les resultats gen raux qu'elles lui ont fournis et qu'on peut reduire aux suivans : 1°* Les vaisseaux absorbans n'absorbent dans aucun cas ni l'eau, ni l'air, ni les matieres qui y sont melees ou dissoutes; 2°* l'epiderme qui les recouvre exadlement dans 1' tat sain, les empeche absolument de faire cette fondtion, et ils ne l'ex- ercent qu'au-dessous de cette croute; 3°« Les matieres dissoluble? -9 226 sont peu-a-peu enlevees ;t l'eau qui les dissout par l'humeur de Ii transpiration plac e a l'extremite des vaisseaux exhalans, lorsque cette humeur ne coule point en torrent comme dans la sueur, on lorsque les vaisseaux ne sont point resserres comme par une tem- perature trop basse; 4?°* les matieres liquides ou fluides elastiques ne sont point admises dans les vaisseaux exhalans, toujours pleins de l'humeur transpiratoire qui y s journe ou qui y est dans un mouvement inverse a. celui de l'absorption ; 5°- les matieres caus- tiques s ches ne sont absorbees qu'apres avoir detruit et corrode l'tpiderme ; 6°- les matieres seches non solubles ne peuvent pas- ser dans le systeme lymphatique, que lorsque par une friction plus ou moins forte on les a fait penetrer a travers les mailles et les pores de l'epiderme jusqu'a 1espace ou s'ouvrent les bouches des vaisseaux absorbans. "A ces tnonc^s, qui rtsultent immediatement des experiences indiquees, M. Seguin en ajoute d'egalement importans, qui ne sont que des consequences n^cessaires des premieres et dont nous expo- serons ici les principaux: 1°* les maladies epidemiques se con- tracted par la voie de la respiration, et les miasmes dissous dans l'air d.pose dans les poumons sont absorbs par les vaisseaux ab- sorbans de ces visceresqui, depourvus d'epiderme, jouissent d'une force absorbante tres-entiere; 2°- le diabete ne provient point de l'eau absorbte dans l'air par la peau, mais du reflux de celle qui ne peut pas etre enlev^e aux poumons par Fair trop charge d'hu- midit-; 30, les amas d'eau ou les diverses especes d'hydropisies ne dependent que de la difference d'adtion entre les vaisseaux ab- sorbans et les vaisseaux exhalans; 4°- resorption commune dans les absorbans par le vuide qui y est produit, soit par la diminution de pression, soit par celle des stimulus, leur structure valvulaire interne, determine le mouvement des fluides de leur exUvmite vers le syst-me des vaisseaux sanguins; 50, les matieres acres et stimulantes, en faisant contracter les vaisseaux, arretent l'absorp- tion ; l'affinite des substances a absorber avec les vaisseaux absor- bans d.termine egalement cette fonction; telle est la difference d'action des matieres nourrissantes et des purgatives, par rapport au systeme des vaisseaux absorbans abdominaux; 6°. enfin les vi- rus contraires penertent par les poumons; l'epiderme est un rem. part qu'ils ne peuvent franchir dans l'etat sain et dans l'integrite parfaite de ce tissu, et ils ne peuvent pas etre absorb-s par la peau." La Medec'wie eclairee par les Sciencis Physiques, vol. iii. p. 2iJ4. I think it unneceffary to make any obfervations on this extract, which will convince every candid mind that our 22J conclufions refpecting cutaneous abforption have been hafty, if not wholly erroneous. 1803. As the inquiry repedting the abforption of the furface of the body is not lefs important than curious, and as this incidental notice of it has excited confiderable at- tention, I fhall give fome account of the experiments on this fubject, publifhed at Philadelphia, in 1800, by Dr. Baptilte Clement Rouffeau, of the ifland of Hifpaniola. The fubflances employed by Dr. Rouffeau, were, fpirit of turpentine, mufk, garlic, and camphor; and thefe were felected, becaufe on abforption, they produce an effect on the fyftem which is obvious and eafily afcertained. He , details his experiments, however, with fpirit of turpentine only, thofe made with the other fubflances correfponding with them entirely. To afcertain the effects of fpirit of turpentine when ab- forbed, Dr. Rouffeau fwallowed a few drops diluted with fugar and water. The effect was as he expected—in a lit- tle while his urine had a ftrong fmell of violets. This effect always follows the introduction of fpirit of turpen- tine into the fyftem through whatever channel, and is, as Dr. R. believes, peculiar to that fubftance. In order to afcertain the uniformity of this effect of the fpirit of tur- pentine, he had it thrown up into his rectum, in the form of a clyfter, mixed up with the yolk of an egg, and dilu- ted with tepid water. The clyfter was retained, and no doubt abforbed. In an hour, the urine fmelt flrongly of violets, and the breath was flrongly impregnated with the flavour of turpentine. He inhaled from a narrow necked bottle, containing fpirit of turpentine, a dozen times; put the bottle away, and went out into the air. An hour af- terwards, his breath fmelt flrongly of turpentine, and his urine had a ftrong violet flavour. Defirous of trying how fmall a degree of inhalation would produce this effect, at another time he made one fingle full infpiration in the fame manner, and put the: bot- tle away. In the courfe of an hour, his urine was very fenfibly affected with the violet flavour, as before. 228 He poured a phial of fpirit of turpentine on a table in a clofe room, and walked backwards and forwards for half an hour. At the end of this time, on examining his urine, it had the peculiar violet flavour. The abfotbing power of the lungs, and the rapid effect produced by it on the circulating fluids, and even on the fecn-tions, being manifcfl, in the experiments made by Dr. Rouffeau to determine the queftion refpecting the abforp- tion of the furface of the body, great care was ufed to guard agaift the action of the lungs. Having provided a long pipe which communicated with the external air, he breathed through it, cautioufly excluding all communication with the air of the room in which he fat. He then poured out the fame quantity of fpi- rit of turpentine on the table as in the forgoing experiment, ftripping off his clothes, and expofing the furface of his body to the emanation. He continued in this fituation for two hours, but no effect was produced on his urine, either at the end of that time, or for the whole day af- terwards. He immerfed his arm in fpirit of turpentine for two hours, lu ing the veffel containing it to the fkin, fo that no vapour could efcape; no effect was produced on his urine or refpiration, though in the courfe of the experiment, the fingers became painful and inflamed, from the irritation of the fpirit of turpentine. He fineared his body all over feveral times with thefpi- ritof turpentine, guarding againft the inhalation of the vapour by the lungs, by breathing the external air through a tube, as before defcribed. He continued this fome time. The furface was irritated, and pulfe quickened, but no effect was produced on the urine. Thefe experiments were frequently repeated, and with the fame refult, whether the fpirit of turpentine was employ- ed, or camphor, garlic, or mufk, as has already been mentioned. Thefe refults have led Dr. Rouffeau to doubt of the ab- forption by the fkin, even in cafes where friction is em- 229 ployed, as in the inunction of mercurial ointment. In the heat of the furface of the body, he thinks that mercurial vapours may arife from it, and be abforbed by the lungs, thus producing the fpecific effects of mercury on the fyf- tem. In fupport of this fuppofition, he mentions the cafe of M. Achard, as given in the Journal de Phyfique, for October, 1782, who having left a difh, containing 20 lbs. of mercury, over a furnace that was daily heated, and be- ing himfelf expofed to the vapours, experienced a falivation at the end of a few days, as did two other perfons who had been expofed in the fame manner. I am not how- ever difpofed to agree with Dr. Rouffeau in this opinion. I think with M. Seguin, that the oxyd of mercury is, by the mechanical action of the friction, made to penetrate the epidermis, and to come in contact with the mouths of the abforbents which lie under its furface. The fame feems to be the cafe in the inunction of opiate ointment, by which the fpecific effects of opium may certainly be produced on the fyftem. I am alfo of opinion, that there are parts of the epidermis fo thin, and of fuch extreme fenfibility, as to admit of abforption through them, without the aid of fric- tion. I fpeak of the glans penis, and of the lips. A melancholy proof was afforded me of this circumftance, in the cafe which I have mentioned, (p. 133), where hy- drophobia proceeded from the faliva of a rabid dog appli- ed to the lips. I have alfo been inclined to believe, that in thofe cafes, where the naked body is immerfed for a. con- fiderable time, in vapour, or liquid, of a nature that fti- mulates the epidermis, though it may not deftroy it—as for inftance in the nitric acid bath—that abforption may take place; but the extreme facility with which the lungs abforb, lead me to doubt the inference from the experiments which fupported that conclufion. And in regard to the experiments, which have been fuppofed to prove the ab- forption of the gafes by the fkin, I fairly acknowledge that I doubt them entirely. On the whole, the principal function performed by the furface of the body is perfpira- tion or tranfpiration, and the principal ufe of this function is to regulate the animal heat. Under this point of view, which has been hitherto almoft wholly overlooked by phy- 230 fioloo-ifts, perfpiration affumes its true character, and be- comes an object of the firft importance both in health and difeafe. CHAP. XX. Population of Liverpool. Prevalence of Fever among tht Poor. Benefit derived from the Manchefter Houfe of Recovery in Contagious Difeafes. Hiftory of the EJla. blifhment of the Liverpool Houfe of Recovery. ExtraR from the Report of the Phyficians refpetling the Means'ij preventing Contagious Difeafes in Liverpool. THE Typhus, or low contagious fever, prevails in all large cities and towns to a degree that thofe are not aware of, who have not turned their attention to the fubject, or whofe occupations do not lead them to mix with the labouring poor. In Liverpool it has been fuppofed that this difeafe is feldom to be met with, and it is certainly true, that the upper claffes of the inhabitants are not often fubjected to its ravages. In the laft twenty years, it has only once fpread among the higher claffes fo as tooccafion any general alarm; and when the extent to which it is con- ftantly prefent among the poor, fhall be proved by authen- ; tic documents, this circumftance will ferve to demonftrate the narrow fphere of the contagion, and to fhew how much it is within the limits of human power to leffen the fre- quency of the difeafe. Before we produce thefe documents it will be proper to offer a few general obfervations. The population of Liverpool, as taken by actual enume- ration, amounted on the firft day of January, 1790, to 57,961 perfons. In the returns made to Parliament under the " Act for taking an account of the population of Great Britain," the number had rifen in the beginning of 1801, - to 80,759; being an increafe of 22,798, in a little more 23I than eleven years.* Of the inhabitants of Liverpool it 1*5 afcertained, that about 9500 live in cellars under ground, and upwards of 9000 in back houfes, which in general have an imperfect ventilation, efpecially in the new ftreets on the fouth fide of the town, where a pernicious practice has been introduced, of building houfes to be let to labour- ers, in fmall confined courts, which have a communication with the ftreet by a narrow aperture, but no paffage for the air through them. Among the inhabitants of the cellars, and of thefe back houfes, the typhus is conftantly prefent, and the number of perfons under this difeafe that apply for medical affiftance to the charitable inftitutions, the public will be aftonifhed to hear, exceeds on an average, 3000 : annually."j- * The enumeration in 1789 was made by Mr. Mikin Simmons, and publifhed in Mr. Gore's Directory in the year 1790, but omitted in the later editions. It occupied him three months, viz, from October 13th, 1789, to January 13th, 1790, and was executed with great care and accuracy. Mr. '■< Simmons gaye the population of each ftreet, ieparately, enumerating alfo the front houfes, back houfes or cottages, and the inhabited cellars, with the number of perfons in each of thefe difcriptions of habitation. The general " refult was as follows : : Front houfes.....6540, containing 39,118 inhabitants ; Back houfes or cottages, . 1608, containing 7,955 inhabitants Inhabited cellars, . . . 1728, containing 6,780 inhabitants Workhoufe and other charities ....... 1,879 inhabitants There weie befides empty 1 houfes, $—717. Making in all, . . . 10,593 houfes, or if the cellars be deducted, 8,865 houfes, containing 55,732 refident inhab, But in eftimating the population, one twenty-fifth part fhould be added for failors, according to the rule laid down by Mr. Rickman, in his " Ob- feivations on the Refults of the Population Act." This will make an addi- i' tion of 2229, making in all 57,961 perfons. The Return in 1801 was 11,446 houfes, inhabited, and 338 empty; in ah 11,784 houfes, containing 77,653 refident inhabitants. To this add a twenty- fifth for failors, and the whole number is 80,759 perfons; being an increafe : of 2919 houfes, and 22,798 inhabitants, in eleven years, and a few months. f From the fit ft of January 1787, to the laft of December 1796, inclunve, . a fpace often years, it will appear by the ;able which follows, that 31,243 cafes of fever were admitted on the books of the Difpenfary alone, which on an average is 3124 yearly. If it be fuppofed that fome cafes may be deno- minated typhus by miftake, let it be confidered, how many cafes of tlii; difeafe do not appear on the books of the Difpenfary, though occur!ng among the poor, being attended by thefurgeons and apothecaries of the benefit clubs to which they belong, &c. The lift of difeafes on the books of the Difpenfiu v has not been kept with equal accuracy fince that period, owing to the fiequ^n: changes in the apothecaries and fccretr.ri^s fince the death of Mr. Avium. 232 The public charitable inftitutions in Liverpool for the relief of the fick poor, are the Infirmary and the Difpenfary. Fevers, by one of the original rules of the Infirmary, are excluded from that hofpital, though this rule, as may be feen from the narrative with which this volume commences, has been occafionally departed from. But with a few ex- ceptions, the care of the poor in fever falls on the Difpen- fary. Of this inftitution I was for feveral years one of the phyficians, and fuch of my remarks refpecting it as are not fupported by authentic documents, are founded on perfonal obfervation. Unlefs in cafes where they are removed into the Infirmary, the care of almoft all the inhabitants of cel- lars, when fick, and of a great part of the inhabitants of the back houfes or cottages, devolves on the phyficians, fur- geons, and apothecaries of the Difpenfary. This defcrip- tion of perfons, amounting in all to about 18,500, do not appear to be healthy, the number of cafes admitted annually on the books of the Difpenfary, on the average of ten years, exceeding 13,000. In the commencement of the year ^iio, a regifter of thefe cafes was begun by Mr. Avifon, late apoctheary to this charity, and continued by him to the fummer of 1797, when he terminated a life of fpotlefs inte- grity, fingular ufefulnefs, and inceffant exertion.* From this valuable record I have formed the following table. * I infert the difeafes of September 1790, extracted from the Regifter, which at the fame time will convey a fpecimen of our moft prevailing difeafes, and fhew that inflammatory and fymptomatic fevers are not included under the genera! title of fever. September, 1790. Febris 310 Catarrhus 24 Debilitas '9 Opthalmia 59 Dyfenteria 2 Hydrops II Cynanche n Cephalagia 10 Scorphula 11 Penumonia 28 Apoplexia Rachitis Hepatitis Paralyfis 4- Syphilis 24 Gaftritis Dyfpepfia 21 Icterus 1 Phtiiifis 19 Epilepfia •I Dyfnria i Rheumatifmus 5* Afthma l6 Vermes i Eryfipelas 8 Pertuflis I I Plora M> Variola Colica *4- Partus Difficilis 1 Rubeola 29 Cholera 24 Uftio >♦ Scarlatina Diarhcca 24 Ulcus 16 Aphtha 13 Hyfteria 4 Vulnus »9 Hoemorrhois . 3 Convu!;. 1 2 — Hcemorrhagia i Ir.fania i 1086 233 c-.oi^wto-otooo-jaiOi'^wtoi-'O £2 1—1 00 p—l p—1 P— p—l >—1 p—l p-^ p—l i-* p—i p—l ^ (0 »-< >0 o o 00 lO co p^ o o CD o -J CO p—1 00 00 Cs to CO C71 » © to ><»■ h- to CD 30 CD 00 -I © CO CO a CD o 00 ~" 00 --t 00 -4 en to to to to ©0 cn OS 00 o p—l p—i 1—J . . , . p-^ p—l p—l <*- OO p—1 to 1—1 o 00 p_• o o CO oo to © --1 *» OS CO o *■ M ,^ co ^ >—> 4* p—' P— to to h-> p— p-^ © © CO © CO to to © CO -I © CO 00 to p— to p—i Cn CD OS 00 en CO 9*" -4 00 os OS -J OS p—1 CO oo C7S o OS OS Cn p^ OS ~ ~J l^-l Cn p—1 ,_, p—' P-J p—l p—i p—l k CO CO CO o o o p—1 c CO p—i ce o 00 00 o os 00 OS s: CO p—' ** CO OS p—' p—l o 00 p—i to p—l Cn -J OS p— 00 -J 00 00 Cn co Cn 00 to p—1 o en fc— o O ^1 to co CO to s ^ ,_, >_, p—l ,_ ,_, tmt ,_, *—1 f° OS co o — p—l co to o o O 00 co o CO © -~1 CD Cn ^V -1 00 OS OS to UO p^- CO p—1 o OS 00 © to Cn to 00 en >~l. CjO •*»• *■ © 00 Cn *~ 00 -4 CO CO o en CO o to *■* ^1 ^ — o p—i £a CO o to o oo 00 to p—l CO CD 00 00 © CD © M NS CO p>—' 00 Cn to 00 4" en -X © to p£- CO Cn 00 CO oo p— to <*< oo -4 co to Cn to ^l en CO ^1 00 en ~4 p$* ■^ OS to en p— -4 ,_, ^ tn CO oo oo to p—l to p—1 CO CD CO 00 CO o CD ^t © ^4 OS GO en Cn Cn CO Cn CO o no 00 r" o -J o OS tn 00 >*»■ to to •— 00 00 to en to *• p—. c ^ 1—1 -4 1-J M l_- P-^ >w p—l ,_ ,_, p—i p—l b OS to to to —1 o o o O p—i CD CO GO © CO -r © 00 CD oo o -J en 00 CO 00 CO >f* o Cn 00 o os OS CO Cn <^ 00 os o CjO CO c 00 *- en O o CD Cn CD os © CO en ^ to 00 oa C31 00 00 pf- H*- 00 to u~, p—i CD w c to OS 00 4* to to CD ^1 to p—i CD p—l OS M -i CO a o o US os 00 *>■ o 00 © ^J os © p—i CD to CO p£> -1 >, sJI •— cn -1 to p^ c -J 00 p— 02 © en CO 00 00 CO X ~4 ^ bi 5^ § 1^ CO > 5?. &!' a o »l O w w > H > 30 234 By the foregoing table it appears, that the number of patients admitted under the care of the Difpenfary annually, taking the average of the feventeen years preceding 1797, is 12,548. But if the ten years only preceding 1797 be taken, the average number will be found to be 13,355. It appears that the greateft number of patients admitted in any one year up to 1797, was in 1795, amounting to 15,235, exceeding the average of the laft ten years by 1880 j and that the fmalleft number admitted for the fevcn years up to 1797, was in 1796, falling ftiort'of that average by 354, and of the number admitted in 1795, by 2234. When it is confidered that the difference between thefe two years falls chiefly in the winter and fpring months ; that the winter and fpring of 1795 were the coldeft, and thofe of 1796 the mildeft, experienced in our climate for a long feries of years; thefe ftriking facts will corroborate the ftatements of Dr. Heberden, in proving that the common opinion, which fuppofes a mild winter in our ifland to be unhealthy, and a fevere winter to be favourable to health, is in both particulars the reverfe of the truth. It appears alfo, that though the number of patients in the winter months of 1794-5, greatly exceeded the general average, yet it was in Februa y, and more efpecially in March, that the excefs rofe fo-very highj on this laft month the aftonifh- ing number of 2003 patients having been admitted. In the three preceding months the cold had been intenfe, but in March the weather became warmer, uncertain, and (lormy. Hence it appears, that though intenfe cold is dire&ly un- favourable to the health of our poor, yet that it is in the tranfition from this intenfe cold to warmer weather, that their conftitutions fuftain the fevereft (hock; a pofition that is ftill more fully fupported by the decifive evidence, that the month of March is the moft unhealthy of the year, and next to it the month of April, taking the average of feven- teen years together. On the fame evidence we may ftate the fuccefllon of the months in refpeel to their unhealthi- nefs in the following order—March—April—January— Oclober—May—December—November—February—junt 235 —September—July and Auguft* But though on the whole, fummer and autumn are more healthy than winter and fpring, the difference is perhaps lefs than might have been expeded; and the difference even between the two months that forms the extremes, is not very great. In the feventeen years recorded in the table, the average number of patients for each month of the whole is 1045 -, the average number in the month of March is 1204; in Auguft 940* Thefe obfervations however are ftri&ly applicable only to a particular defenption of perfons in a particular fituation— to the poor of Liverpool—and without the corroboration of other documents, muft not be extended to the general mafs of fociety, or to the kingdom at large. I proceed to give, from the fame authentic regifter, the table of typhus, the more immediate object of our inquiries. * It appears that June Hands in the table higher than May or December, but this arifes from the vaft number admitted in June 1781, when the influen- za was prevalent, and was confined nearly to that month. Allowance being made for this, June will frand as inferred 236 ^ o ■-I a Ml ^ V il ^> , a •J < < "11° P4.-8 a OS 51 t—I 0> R CO £ r~ co co i— o* •* »o t~ t— co © ■* 1—1 »o '0 © x rHiHUS'-Hoscocor-iDo')r~'*>o(MCi-C) os—1 (M » Oir- ^ -* —« OS •* co —< os •«}< as co ,—iO104O40404O4COCOO4 0OGOc0O4C0O4Oi Q v cocoxeot~04r^coioxas—<-*xco©r^ cnojici^osooosoiosOcor^r-CNOioO'* —iojp—i^^p-intntN^wnr-• 04 co p—i 04 5s © 00 © r- os ■* r- 00 10 ■* 1-0 10 04 ** x 1> CO I — o CO ■* CO CO 1—1 0 10 CO l-H 01 10 —1 10 0 £ f"H 04 1—1 04 00 04 rH Ol CO Ol CO CO 04 04 01 CO *""' 04 «l %1 CO ** 04 CO f- O ,_, ■* _H ■* © ■* © lO 0 os OS (X i-5i 0 cso 80 CO *^ ■* iO —H CO •* r—1 ■* •* no O OS CO 04 01 1—1 04 1-^ 00 04 04 04 04 00 04 CO CO CO CO 04 04 CO "5 ■* v." os r- 60 «3 CO CO os 00 00 Ol © 0 l-H CO CO CO * i.n 05 CO ■* CO CO X CO -H K5 0 l-H CO 0 OS 10 01 p—i p—1 P-H 04 04 .•H l-H 04 04 G4 CO CO 04 CO CO 04 cn co cn "*4 O r- © t- O © X Ol ,_ 04 © CO CO r^ 10 O) CM pH a us 04 ■* 04 00 CO X OS p—i CO r- ■* Ol os ■* «S 00 o l-H ■* CO CO CD OS _ CO CO 01 os ws 04 00 r- r- LO 10 r- oc ■* CO CO OS os T* © in ~ r—1 04 04 p—1 04 04 " CO 01 04 l-H 04 04 04 00 on <£ CO ■# OS 04 »0> r~ 10 CD 10 10 r^ 0 r- ■* »o O CO 0 CO ^J- OS 04 «5 r- 10 CO iO iO r^ 0 r- ■* to © CO 0 a CO >o >o —H 04 00 10 10 ■* © •* 1* 00 CO 0 on r- in « P-H l-H P-H 04 04 l-H l-H CO 01 CM 04 04 04 CO CO 04 p-H 00 «S tn P^v X r^ CO CM 04 OS 01 CO CO .^ ,_, CO r^ t- -* X cn ,« CD CO ■* 01 CO —H 0 p-H •Ol os 00 CO CO CO -^ CO X 0 ^ l-H P-H 04 CM 04 CM CO 04 CO 04 01 01 04 CO Ol 04 ji »«^ CO 0 04 r^ r- ■* ■* ■* iO CO ■>* 0 00 cn © "•# 01 CD is t- © OS © ■* OS <* CO lO 04 OS 30 r- 10 X, 0 "* in * 04 04 CM 04 04 04 04 Ol CO CM 04 04 04 04 04 04 CM 5? OS O ^ ■* IO CO CO l-H CO 00 r- r- OS _ CO CO CO 01 r- 00 CO CO ■* OS -H O -H CO co r- CO CM X ■* CO 00 tS P-H l-H 04 l-H G4 CM CM CO 04 CO CO 01 01 CM 50 IO 04 CO ^ •* 10 CO 10 CO -* 00 CO OS «* CO CO h- f OS © Iti -H 01 01 ** CO 10 OS CO CD © r^ r^ ■* Tf CO © 00 co co 0 f*i l-H P-H Ol i-H 04 CM p-H "^ 04 04 CO 04 04 CM rH CO on © © 00 0 0 •0 —H CO CO © co CO OS ■* r- 01 r- on $5 >o CO CD -* f- CO os 10 CO — r- 10 10 r- 10 'O © 00 01 04 04 p-H 04 CM CO 04 CO —i —H l-H l-H CD en OHCMcn^incohcoosOi-1 01 on •* in co xxxxxxxxxxcsosososososos t^ i> r^ r— r~ t^ r~ r- r^ r— i- t- t^ r- i^ t^ x^ S 237 Thus it appears, that of 213,305 patients admitted in the feventeen years preceding 1797, at the Difpenfary, 48,367 have laboured under typhus; nearly a fourth of the whole ; an immenfe proportion ! It is curious to obferve, that March takes the lead in refpect to the prevalence of fever, as well as of difeafes in general, and that Auguft, as before, brings up the rear. It appears alfo, that the month of March 1795, which exceeded every other month in the production of difeafes in general, exceeds in a ftill greater proportion in the production.of fever j no lefs than 546 patients having been admitted in that month under this fingle difeafe. The year 17 95 has not however the fame un- fortunate preemience here as in the table of general difeafe, being furpaffed in the number of fevers by feveral others. But the year 1796 enjoys a fimilar diftinction as formerly, having produced fewer fevers than any other of the laft ten, and 545 fewer than the average of the whole. Taking the feventeen years in the table, the average number of fevers annually is 2845, and the average number monthly is 237. The average number of March rifes to 275, and of Auguft, finks to 202. On the whole the prevalence of fever is greater, and the influence of feafons upon it lefs than might have been expected, For the ten years preceding 1797, there were, on an average, 119 patients ill of fever conftantly on the books of the Difpenfary ; or if the feventeen years preceding 1797 be taken, the conftant average number will be 109. Of convalefcents, unfit for labour, the average number will be nearly as great. Thus, in Liverpool, 240 of the poor may be confidered as conftantly rendered incapable of earn- ing their fubfiftance by this fingle difeafe, and as the poor feldom lay up any part of their earnings for a feafon of ficknefs, the expenfe of their maintenance muft, in one form or other, fall on the public. If we take this as low as 10I. for each, it will amount to 2400I. annually.* * Thefe calculations will not be expected to be minutely correct, but I ap* prehend they will in general be found under the truth. The average number of fevers annually for the laft ten years, is 3124, and the mean duration of each fever is fuppofed to be fourteen days; 1^||-14S=MQ.8 daily. If the 238 It would afford me particular pleafureto introduce authen- tic documents of the fuccefs attending the treatment of the typhus by my brethern of the Difpenfary ; but the valuable regifter which furnifhed materials for the preceding tables, does not mark the iffue of the particular cafes. In general however it may be afferted, th?t where the affiftance of the Difpenfary is reforted to in time, even under the difadvan- tage of being attended in confined and dirty habitations, a great proportion of cafes terminate favourably. The gene- ral treatment of fever at the Difpenfary, confifts in giving antimonial emetics in the firft inftance, and afterwards bark, opium, and wine. Nourifhing food is occafionally adminiftered. Ablution with cold water has been ufed lefs than could be wilhed, and indeed it is in general diffi- cult to employ it in the obfeure cellars in which this dif- eafe is ufually found. The fever that prevails among our poor is remarkably uniform : it is the pure typhus, to which the cordial treatment can be applied with fafety, and to a great extent. Whereas among the higher claffes, fe- ver is often attended with inflammatory fymptoms in the firft inftance, fometimes with pneumonic fymptoms through a confiderable part of the difeafe j and in fuch cafes, the indications of practice being contradictory, fuc- cefs is much lefs certain. Though the cure of this difeafe is a principal object of our charitable inftitutions in Liverpool it is to be lament- ed that hitherto little or nothing has been done for its pre- vention j although it may be confidently afferted, that this object, great as it is, is not beyond the reach of human power.—This infection arifes from a want of cleanlinefs, and ventilation ; and its influence is promoted by damp, fatigue, forrow, and hunger. When the fubject (hall be ferioufly taken up by the public, the means of fecuring cleanlinefs and ventilation, even in the greater part of our fubterraneous dwellings, may be clearly pointed out -, and average of the laft feventeen years be taken, this will give 2845 annually, which produces on the fame principles 109 daily. I calculate that the period of convalescence after each fever is fourteen days, or upwards, which gives tht lame number of convalefcents as of patients in fever, deducting thofe wbo may die, a much finaller proportion than could well be fuppofed. 239 though the fecondary caufes, if I may fo call them, feem lefs capable of being removed, yet much may be done to alleviate them, when a comprehenfive inquiry into the con- dition and wants of the poor, (the moft preffing of all ob- jects in the eye of enlightened patriotifm), lhall engage the attention of the legislature.* Important information in regard to the means of pre- venting the generation and progrefs of .contagion, may be found in the writings of phyficians of our own country and neighbourhood ; of Dr. Percival and Dr. Ferriar of Man- chester, of Dr. Campbell of Lancafter, of Dr. Haygarth of Bath, and Dr. Clark of Newcaftle. The perfevering exer- tions of Dr. Percival, Dr. Ferriar, and the other gentlemen of the faculty attending the Manchefter Infirmary, have produced an inftitution in that town, which deferves to be imitated in every large city and town in the kingdom ; a houfe of reception, or as it is juftly called, a Houfe of Recovery for the poor, when labouring under fever. Into this afylum, on the firft notice of difeafe, the patient is immediately removed, and proper methods taken to purify his habitation. By thefe means the contagion is extin- guished in its birth, and the patient himfelf being re- moved to a fituation where all the refources of art can be employed with advantage for his benefit, and removed at a period of the difeafe when thefe refources are of great avail, is very generally reftored in health to his family and to the community. The benefits of this admirable infti- tution in Manchefter, no longer reft on the bafis of the- • The want of a diet fufficiently nutritious, is doubtlefs one of the caufes that promote the typhus, and other difeafes, among our poor. This does not feem to aiifj in general fiom the price of their labour being inadequate to iurnilh fuch a diet, but from their ignorance in the moft advantageous modes ef cookery, and ftill more from iheir indulging in articles that confume their means without adding to their fuftenance. In the eighteen iiundred cellars in Liverpool, theie are many in which animal food is not tafttd more than once a week j but there aie very few in which tea is not drunk daily ; it is often indeed drunk twice a day. The money fpent on tea is worfe than wafted. It is not only diverted to an article thai fu, nifties no nutrition, but to one that debilitates the empty ftomach, and incapacitates for labour. Hence the vail number of dyfpeptic complaints among our patients at the public chaii» ties, which are alinolt all to be traced to the ulie of tea or fpirits, often indeed afillted by depreflion of mind. At the Infiimiy and Difpenfaiy together, this clafs of patients exceeds five hundred annually. The great majority a™ females. 240 ory; they are eftablifhed on the immovable foundation of fact and experience. The prevalence of fever in the town is diminifhed to a degree that has exceeded all rational expectation ; and the fears entertained, that the Houfe of Recovery might fpread the contagion through the ftreets in its vicinity, are found to be entirely groundlefs.* * The following facts are extracted from the Report of the Board of Health, dated Manchefter, May z6tb, 1797. Since the eftablifhment of the Houfe of Recovery, the whole number of home patients (i. e. patients requi- ring attendance at their own habitations), is reduced one half; but the num- ber of fever cafes, in a far greater proportion. In January 1796, 226 cafei of fever were admitted at the Infirmary of Manchefter, but in January 1797, only 57. Fears had been entertained that the fever might fpread from the Houfe of Recovery into the neighbouring buildings, and fo through the town, and this had given rife to a confiderable oppofuion. The ftreets in the imme- diate vicinity of the Houfe of Recovery, are Silver-ftreet,Portland-ftreet, &c. In the firft eight months after the eftablifhment of the Houfe of Recovery, the number of cafes of fever admitted on the books of the Infirmary from theft ftreets was 25. In eight months of the preceding year, viz. from the 20th of September, 1795, to the 20th of May 1796, the fame ftreets furnifhed td-j cafes of fever. From the 20th of September 1794 to the 20th of May 1795, they furnifhed 389 cafes} and from the aoth of September 1793 to the 20th of May 1794, 400 cafes. Facts fuch as thefe, require no comment; they have made a forcible impreffion in Manchefter, as might be expected, and the report 1 quote contains public teftimonies in favour of this excellent In- flitution from the Board ol the Infirmary, the Stranger's Friend Society, and The Special Board of the Poor. The total number of fever-cafes received into the Houfe of Recovery from its being opened, the 19th of May 1796, to the 31ft of May, 1797, is......371 Of thefe are difcharged cured, . . . 324 Dead, ....... 40 Remaining, ...... 7 ----37i The benefit of this inftitution is not to be calculated by the number of perfons cured. Every fingle removal into the Houfe of Recovery, probably prevents on an average two or three cafes of the difeafe. As the inftitotion goes on, it may be confidently predicted, that the proportion of cures will be ftill greater than here ftated, becaufe experience will induce the poor to apply for relief in the early ftages of fever, when the power of medicine may be exerted with the greateft advantage. I have the authority of Dr. Ferriai for faying, that fince the 31ft of May to the 25th of September, two perfons only have died in the Houfe of Recovery. 1803. The advantages at firft derived from the Houfe of Recovery at Manchefter, have not continued in an equal degree, owing to the difficulty of enfoicing cleanlinefs and ventilation in the habitations of the poor, difficul- ties particuhily great in Manchefter, where such fudden fluctuations occur in the numbers of the lower claffes. The importance of the Houfe of Reco- very is however univerfally admitted there, and a new building to contain xoo beds is now projected for that inftitution. 241 The utility of the Houfe of Recovery in Manchefter \vas ftill more completely afcertained in the courfe of the fummer of 1797.—" Within thefe laft four months, (I " copy a paragraph in a letter from Dr. Ferriar, in the u month of September of that year), we have been threat- " ened with the return of an epidemic fever, and dan- " gerous cafes of typhus have appeared in every quarter " of the town; yet by felecting thofe patients who were, " from their fymptoms and fituation, moft likely to com- " municate infection, and by removing them into the fever- " ward, the weekly lift of home patients has been pre- " vented from increafing much beyond their ufual number. fe Our Houfe of Recovery, which contains accommoda- " tions, for twenty-eight patients, is fufficientfor Manchefter " at prefent. In the event of a peace, and the influx of " new inhabitants which it muft occafion, it may be ne- ct ceffary to provide accommodation for a greater number. •' But I think fever-wards capable of containing fifty u patients, with feparate rooms for the reception of cafes " of Scarlatina Anginofa, Meajles, or Small Pox, would " anfwer every purpofe here, in times of the greateft emer- " gency, even fuppofing a very confiderable increafe of " population." Till the latter end of the year 1787, there was no place for the reception of fever, or any other contagious difeafe, in Liverpool. At that time the fever broke out in the Infirmary, defcribed in the 21ft page of this volume, and two wards being fitted up for the patients infected, one for each fex, thefe were afterwards occupied by fuch cafes of fever as occafionally prefented themfelves. The reception of fever into thefe wards continued for five years and one month, during which time 232 cafes of fever paffed through them. The wards were fmall, and under ground; in every refpect inconveniently fituated. They held at moft eight beds each, but were properly adapted to fix beds only. But they admitted of cleanlinefs and ventilation, and it was there that an opportunity was af- forded of employing the affufion of cold water; of remark- 3* 242 ing its effects; and of eftablilhing the rules that ought to regulate its application. From the firft however, the admiffion of fever into the Infirmary, (which was contrary to one of the original rules of the inftitution), was objected to by fome of the friends of that charity. They allowed the benefit arifing from a receptacle for fever, but they contended that the Infirmary was not adapted to that purpofe; and that the attempt to render it a hofpital for fever, the wards already mentioned being all that could be allotted to that difeafe, did not afford the relief required, while it obftructed the original purpofes of the inftitution. The want of an afy- lum for this difeafe elfewhere overcame thefe objections. But about the beginning of 1793, a contagious fever having prevailed in the Workhoufe, two fpacious wards were fitted up in that building by the Parifh Committee, for contagious difeafes; and an arrangement having been made for the reception of fuch cafes of fever as prefented themfelves at the Infirmary, into the wards of the work- houfe, from that time the admiffion of fever into the In- firmary has ceafed. Contagious difeafes, and more particularly fevers, have in general been excluded from the hofpitals of England, thofe of London perhaps excepted ; but the evidence of our own Infirmary and Workhoufe, of the Chefter Infir- mary, and of various fimilar inftitutions, proves, that un- der proper regulations they may be admitted under the fame roof with other difeafes, without danger of the infec- tion fpreading through the building. It is not however to be denied, that the attendance and the arrangement re- quifite for patients under fever, render it a matter of con- venience and propriety that they fhould be received into a feparate building; and it is a point capable of demonftra- tion, that hofpital* for fuch difeafes ftand pre-eminent in point of utility over all other hofpitals, thofe for accidents that require the immediate affiftance of furgery alone per- haps excepted. The benefit derived from hofpitals in other cafes confifts in removing difeafe, and is confined to the patient himfelf j but in cafes of contagion, the evils pre- 243 vented are much greater than thofe remedied, and the benefit is by this means extended from the patient himfelf to the circle by which he is furrounded. The eftablifh- ment of fuch hofpitals was firft fuggefted by tracing the infection which propagates fever, to its origin, and afcer- taining the power of ventilation and cleanlinefs in prevent- ing and in alleviating the difeafe, The arguments for fuch hofpitals are ftrengthened by the improved methods of deftroying contagion ; and if I do not greatly deceive myfelf, they are ftill farther ftrengthened by the fuccefs of that mode of practice in fever, which it is the chief object of this publication to explain and to eftablifh. A vigilant exercife of all the means of prevention, and of cure, might indeed in a fhort period fuperfede the ufe of hofpitals, by extinguifhing the difeafe ; a profpect in which the philan- thropift might more fafely indulge, if he could calculate with the fame confidence on the wifdom as on the power of his fpecies. The wards for fever at the workhoufe, have in general fecured that immenfe hofpital, often containing 1200 per- fons, from the fpreading of fever, to which, previous to their eftablifhment, it was perpetually liable; and though they are in the very centre of the building, and cannot be entered but through the common ftair-cafe, yet no fingle inftance has occurred of the contagion extending from them into the other parts of the houfe. They have alfo relieved the Infirmary from the neceffity of admitting thofe mifcrable wretches, who under the influence of fever, (per- haps caught on fhip-board), and refufed admittance into private lodging, were brought up to that hofpital, where, if not received, they might have perifhed in the ftreets. But they have not been of fufficient fize to anfwer the pur- pofe of a general Houfe of Reception for the poor, labour- ing under fever throughout the town, nor has their power ofaccommodation been employed to its full extent with this view.* The phyficians of the Difpenfary, who attend • Thefe fever-wards contain eighteen beds very conveniently, and from the toth of Auguft 1793 "> the 3«'t of Auguft 1797. » *>ace of four year8> anly 5 jo cafes paffed throwgh them. They did not therefore on an a??r:,£c 244 the workhoufe, have authority to remove patients on the firft appearance of fever, from any part of the workhoufe itfelf, into thefe wards; but they have not the fame author rity to remove them from the town. The delay occafion- ed by the forms to be paffed through in obtaining the ad- miffion of thefe patients has very generally prevented the attempt being made, and fometimes where it has been made and fucceeded, has occafioned the relief to come too late. In confequence of confiderations of this kind, a motion was made at the annual veftry, in March 1796, that a fet of fever-wards fhould be conftructed at the expenfe of the parifh, for the general ufe of the poor, on the plan of the Manchefter Houfe of Recovery. Four wards, capable of containing fixty beds, were ftated to be fufRcient for the town; it was propofed that they fhould be erected on the elevated and open ground contiguous to the workhoufe, and be fupported out of the parifh rate. And it was af- ferted, that this would be a plan, not merely of charity, but of economy. The meafure of eftablifhing fever-wards was unanimoufly agreed to, and a committee appointed to carry it into effect; but differences of opinion arofe as to the execution of the plan, and all proceedings on the fub- ject were fufpended for feveral years. It has however been refumed, and is now nearly completed, in confequence of the circumftances about to be related. So far as we can truft the bills of mortality publifhed in Liverpool, and fo far as we may confider the annual num- ber of deaths as a fair criterion to judge by, the general health of the town does not appear to have been very ma- terially affected at any one time during the laft century, either by the prevalence of epidemic difeafes, or by any other caufe. The number of deaths bears a pretty fair proportion all along to the increafing population.* But contain more than fix fever-cafes at a time. Of thefe 530 cafes, ji died, a fmall proportion, confidering that 16 died in 24 hours after admiflion, and were in articulo mortis when received. * The moft ftriking exception to this remark, appears in the year 1770, *,!;:n the number of deaths amounted to 1562, being an increafe of nearly 600 245 in 1800, a fudden increafe in the proportion of deaths took place, which rofe ftill higher in 1801, the whole number being in the firft year 3080, and in the laft 3768. For the two preceding years, the average annual number of deaths was 2406, and this is nearly the number of the year following, (1802), fo that in 1800 the deaths exceeded by 678, and in 1801, by 1362, the ufual number. So ex- traordinary an increafe of mortality, arifing as was evident from the prevalence of contagious difeafes, excited confi- derable attention and alarm, and the motion being renewed in the annual veftry for the eftablifhment of a Houfe of Recovery without delay, the meafure was unanimoufly a- greed on: a fpecific levy of nine-pence in the pound being laid on the parifhioners of Liverpool, for the exprefs pur- pofe of erecting this building, and providing a new ceme- tery for the parifh poor. A plan for the building was gi- ven by the phyficians of the Infirmary and Difpenfary, and notwithftanding fome unexpected delays, the houfe is now in great forwardnefs, and will be ready for the reception of patients in a few months. It is a fpacious building, (land- ing alone in a field by the workhoufe, from which it is diftant about forty yards. It poffeffes every advantage of ftructure and fituation, and will contain fixty, or on an emergency, ninety beds, of which one third, on a fepa- rate floor, are deftined for convalefcents. It is to be fup- ported out of the poor-rate, under the management of a fub-committee, chofed out of the general parifh commit- tee appointed by the annual veftry, and an accurate ac- count of its expenditure is to be kept and publifhed annu- ally. It is not doubted that this inftitution will be found a meafure not merely of policy and humanity, but of eco- nomy alfo.* above the years which preceded and followed it. I ufed here and throughout, the general table of chriftenings, burials, and marriages, and the annual ta- bles of the fame kind, printed by Nevett, and publifhed and diftributed by the fextons, though I am afraid they are often deficient in accuracy. They differ confiderably from the General Table publifhed in the AbftraS of the Anfwers and Returns to the Population A3, p. 149, faid to be coined from the Regifter of the Town of Liverpool, in which the burials for 1770 arc (fated at 2,020. * In ereaing a feparate building, and forming a feparate inftitution for the reception of fevers, the great number of perfons requiring admiffion into this 246 That the Hofpital for contagious difeafes fhould have been erected by the Parifh of Liverpool, and that its an- nual expenfes are to be defrayed out of the poor-rate, are circumftances rather unufual in the hiftory of fuch inftitu- tions. The application of the poor-rate to fuch puipofa is however not only legal, bu.t prudent and wife—of all the purpofes indeed to which it can be applied, this is per- haps the only one which is no lefs flrongly recommended by policy than by humanity. I have purpofely avoided entering into the detail of all the obstructions which this important meafure encountered during the feries of years in which it was under difcuflion, though in fome points of view, fuch a detail might have been instructive. To the credit of the town it was in the end adopted almoft unanimoufly, as it had from the firft been unanimoufly recommended by the gentlemen of the faculty. The effects of this inftitution will however be much limited, if meafures are not combined with it for removing the caufes from which contagious difeafes derive their ori- gin among our poor. Some attention has already been paid to this important object. In the beginning of the year 1802, the corporation of Liverpool, being about to apply to Parliament for powers to improve the ftreets and the police of the town, requefted the phyficians of the In- firmary and Difpenfary tofuggeft to them "fuch alterations " as might contribute to the health and comfort of the in- " habitants," in order, that where neceffary, they might include in the bill about to be brought into Parliament, the powers requifite to carry fuch alterations into effed, The phyficians took this requeft into ferious confideration, and presented a report of confiderable extent, including a hofpital was chiefly confidered. For as I have already obferved, it cannot be doubted, that in fituations where thefe are lefs numerous, the reception of fevers may be fafely combined under proper regulations with the ufual objefli of Infirmaries, as the curious, ample, and moft important collection of docu- ments on this fuhjecr, publifhed by my friend Dr. Clark of Newcaftle, dearly demonftr^tes.—See a Colleclion of Papers intended to promote an Inftitution fa the cure and prevention of infectious difeafes in Neivcaftle—■Newcaftle: print' ui by S. Hodgfon, liOi. 247 view of the caufes of the uncommon ficklinefs of the two preceding years, and of the meafures rcquifite to prevent its recurrence, and to remove the frequency of contagion in the habitations of the poor. To leffen as much as poffible the contamination of the atmofphere, they recommended that lime fhould be prevented from being burnt within a certain diftance of inhabited houfes j that foaperies, tan- yards, and other offenfive manufactories fhould in future be prevented from being eftablifhed in th<- town; apd where now eftablifhed, and authorized by ufage, that they fhould, whenever practicable, be purchafed by the body-corporate, and the fpace they occupy converted to other purpofes. The fame recommendation they extended to flaughter- houfes, and to all other offenfive trades or manufactories. They recommended, that in ail cafes where fire-engines, or fleam-engines are neceffarily employed in the town or its vicinity, the burning of fmoke fhould be enforced, as well as in all other practicable cafes where large volumes of fmoke are admitted.—They pointed out the neceffity of enforcing cleanlinefs in the ftreets, to which end an im- provement of the pavement was reprefented to be effential; and they particularly advifcd a general review of the com- mon fewers, and an improvement of their ftructure, on the principles of report on this particular fubject, addreffed by them to the Mayor and Magiftrates, in 1788. They fur- ther advifed, that effectual provifion fhould be made for draining the grounds within the liberties, and particularly to the north of the town. "Repeated remonftrances (I quote the words of the report) have been made for the laft twenty years, on the collections of Handing water, inclu- ding filth of every kind, which are fuffered to remain in the diftiict which extends along the termination of the ftreets from St. Paul's fquare to Byron-ftreet, and to which the low fevers, which in the autumnal months efpecially, in- feft thefe ftreets, are principally to be imputed. Thefe remonftrances have oeen paffed over, on the ground, as we are informed, that the proprietors of the lands will not agree to the plan neceffary for draining them. It is not to be endured, that the health of the inhabitants fhould be perpetually endangered from fuch a caufe, and we cannot 248 conceive any fubject more proper to be fubmitted to the wifdom of Parliament. " But in a more efpecial manner, we would direct the attention of the gentlemen of the town-council to the ha- bitations of the poor, and in the firft place to the inhabited cellars. The vaft number of perfons that occupy fuch dwellings, and the impoffibility of finding other habita- tions, forbid us to hope that any recommendation for pre- venting rhem from being generally inhabited, could be attended with immediate effect. But a general furvey fhould be made of thefe fubterraneous dwellings, and fuch means adopted for promoting their falubrity as circum- ftances require and admit. Many of thefe cellars are dou- ble, and the apartments next the ftreet, having accefs to the external air only by the narrow and oblique aperture that forms the door, and which is of courfe fhut during the night; and the back apartment having accefs to light and air only by its communication with the apartment in front; under fuch circumftances the generation of difeafe, and efpecially of contagious fever, is almoft a neceffary confequence. In all fuch cafes, a direct communication fhould be made with the external air, by opening a window in each apartment, and where this is impoflible, by introducing a tube to the external orifice of which, an air-pump, of an eafy and Am- ple conftruction may be applied when neceffary, efpecially in cafes of contagion, and the apartments be fpeedily and effectually ventilated. This would in a very confiderable degree facilitate the means of counteracting contagious difeafes, and of rendering the adminiftration of medical af- fiftance fafe to thofe whofe duty call them to adminifler it. Bur, befides this, thefe cellars fhould, in all practicable cafes, have a chimney in each apartment, and open into a back yard, where there is a neceffary, and a fupply of water; and no cellar fhould be inhabited, the ceiling of which is not three feet at leaft above the curbftone round the door way, by which the communication with the external air may be rendered free and direct. Power fhould alfo be ob- tained, to oblige the owners of cellars to whitewafh them, at a ftated time in every year, and at all other times when they may have been vifited by contagion -, and likewife to 249 prevent them from allowing thefe cellars to be inhabited till the plafterof the walls is perfectly dry. " In the application of thefe obfervations to cellars al- ready inhabited, fome modification muft neceffarily be al- lowed, but in regard to all houfes to be built in future, powers fhould be obtained to prevent the cellars from being inhabited at all, except they be conftructed according to the plan juft pointed out." The Report here mentions a few places in which, from local circumftances, the cellars are particularly obnoxious, and advifes, that as foon as poffible they fhould be emptied of their inhabitants, and filled up. It proceeds as follows— " The habitations of the poor in the greater part of the fmall and narrow courts back from the ftreets, are equally objectionable in point of health as in the cellars. It is much to be lamented that fuch a form of building fhould have grown into general practice. * * *. Powers fhould be obtained for preventing ground from being occupied with buildings of this defcription in future, and the pro- prietors of courts already built, might be compelled to give them the ventilation of a thorough draught of air, which would in general be obtained with little difficulty. If any courts are permitted to be built in future, it fhould be on condition that they be made of a certain width; that the entrance fhould not be through an arch-way; that the houfes fhould not be above two ftories high; and that the upper end of the court fhould be kept open.—Every court fhould have two or more neceffaries, according to its fize, and a plentiful fupply of water. " The Parifh are now building a hofpital for the recep- tion of contagious difeafes. The benefit of this will be greatly increafed, if a power is obtained, enabling the ma- giftrates, on the reprefentation of two or more phyficians, of the neceffity of the meafure, to remove the inhabitants of a dwelling declared to be infected into another habitation, till meafures are employed for destroying this infection. For fuch a defirable object, it would be neceffary to have a few dwellings kept for occafional and temporary ufe, in different parts of the town. 3* 25° " But after all, it feems neceffary to adopt fome means for increafing the number, and improving the structure o( the dwellings of the poor. It feems highly defirable to de- termine on a plan, both for the individual houfes, and their arrangement as to each other, that may unite healthfulnefs and convenience, and ferve not only for prefent ufe, but for future example. Such a plan, when perfected, would contribute not merely to the healthfulnefs, but to the beau- ty and regularity of the town, while, at the fame time, it would be of great advantage to the corporation cftate. It would be favourable to induftry and good morals. In the dwellings of the poor, which at prefent too frequently ex- hibit diftrcfs and confufion, might be introduced cleanli- nefs and good order, and decency and comfort might be found in fituations which too often excite fentiments of pity and difguft. " To fuch a change, other regulations would indeed be requifite, and particularly fome means of diminifhing the temptations to the ufe of t intoxicating liquors, a great and increafing evil, but of a magnitude too fenous to admit of its being on the prefent occafion, fully difcuffed." Every attention was paid to this memorial by the gentle- men of the Common Council of the Corporation, and in the draught of the Bill propofed to be brought into Parlia- ment, fuch claufes were introduced as weie neceffary to enable them to carry into effect, the various regulations recommended to their notice. But the interests of different individuals being affected, not merely by thefe regulations, but by a variety of others propofed in the bill, difficulties have arifen in procuring that general affent, fo defirable in all fuch applications to the legiflature. The meafure is however in progrefs, and it is not to be doubted, that by the exercife of candour and patience, every obftacle will be removed, and that the public good will triumph over all inferior considerations. END OF VOLUME J. MEDICAL REPORTS, ON THE EFFECTS OF WATER, COLD AND WARM, AS A REMEDY IN FEVER AND FEBRILE DISEASES, Whether applied to the Surface of the Body, or used Internally, VOL. II. Consisting of the Author's Experience of this Remedy subsequent to the second Edition of Volume I. And of important Com- munications from others on the same Subject. To which are added, Four Letters;—One on the Sphere of Febrile Conta-p- gion ;—Two on the Establishment of a Lunatic Asylum in Li- verpool ;—and One on the Effe&s of Nitrous Acid in Lues Venerea. BY JAMES CURRIE, M.D..F.R.S, Fellow of the Royal College of Phyficians, Edinburgh. Inter.tiones operationum, quas propofuimus (ut arbitramur) veriffima: funt, remedia inten- tionibus fida. * * * Rem ipfam experimentum et comproba-vit et promo-uebit. * * * Opera conjilii cujufque prudentioris, Junt effetlu admiranda, ordine quoaue egregia, modis faciendi tanauam vulgaria. Bacon. Hiftoiia vitae et mortis. PHILADELPHIA PRINTED : FOR JAMES HUMPHREYS, AND FOR B. & T. KITE. 1808. ADDITIONAL REPORTS. CHAPTER I. The Author's more recent Experience of the Ufe of the Cold and Tepid Affufion.—Ufe of the Digitalis in Inflamma- tory Fevers. IN the preceding volume is reprinted my former publi- cation, with feveral additions, and a few corrections, fuggefted by the progrefs of my experience. Such addi- tional obfervations as I have to make on the ufe of water as a remedy in fever and febrile difeafes, I have, however, referved for a feparate volume, in which I fhall include a few of the moft ftriking testimonies in favour of this reme- dy, afforded by the experience of others. In the fix years which have elapfed fince the publica- tion of the fecond edition of the firft volume, I have inva- riably employed the affufion of water, cold and tepid, in the difeafes pointed out in the original publication, and I have extended it to fome others, of which I fhall after- wards fpeak. Its fuccefs has equalled my expectations : I have nothing to detract from the accounts I have formerly given of its efficacy. I repeat—that ufed in the three firft days of fever, the cold affufion very generally flops the difeafe—that the fame happy effects fometimes follow its ufe on the fourth or even fifth day, but feldom later—that even in the fubfequent ftages, where the heat continues preternaturally great, and the fkin dry, it is of great and 254 manifest advantage, almoft immediately relieving the moft diftreffing fymptoms, particularly reftleffncis and delirium, and conducting the difeafe to a fafe and fpeedier iffue. The tepid affufion is, as I formerly obferved, applicable to all the difeafes to which the cold affufion is applicable, and poffeffes very confiderable, though inferior efficacy. I find it however, very fafe, eafy of application, and in a hioh degree grateful, and I have extended it to almost the whole clafs of febrile difeafes. In my practice the cold and tepid affusions are very often combined in the fame difeafe. While the heat is great, the fkin dry, and the vafcular ac- tion ftrong, I ufe water perfectly cold ; when thefe fymp- toms diminifh, I ufe it cool; and as they fubfide ftill far- ther, I make it tepid. The precife meaning of thefe terms is given in chap. x. vol. i. Though, where the fever is evidently of a contagious nature, 1 employ the cold affufion freely, notwithftanding the prefence of pulmonary fymptoms, as in the epidemic in the 30th regiment, mentioned in chap. iii. vol. i. yet in anomalous cafes, where thefe fymptoms are not prefent, I have been cautious in ufing it. In fuch cafes however, I ufe the tepid affufion freely, endeavouring to compenfate for its weaker and more tranfient effect,, by frequency of repetition. A great part of the febrile affections of chil- dren are of this clafs, and to thefe little innocents the tepid affufion is a bleffed and an invaluable remedy. In fevers accompanied by, or originating in high local inflammation, which are generally attended by a great difpofition to chil- linefs, I do not depend on or recommend the ufe of affu- fion, cold or tepid. Neither does my experience enable me to fpeak decidedly in favour of the ufe of cold water as a drink in fuch cafes, though this is flrongly recommended by Dr. Kinglake. It is a point on which I would not be underftood to give an opinion. Is it to be regretted, that where fevers arife fingly in private practice, it often happens that before their nature is fufpected, and a phyfician called in, the beft reafon for ufing the cold affusion is paft. In all fuch cafes, how- ever, ablution may be reforted to with advantage, with 25S water, either warm, tepid, or cold, as the heat of the pa- tient may direct; and by the method of affufion, or fponging of the furface,* as his ftrength'may admit; the firft being dways to be preferred, unlefs in cafes of great debility. By this practice, the patient himfelf is not only benefitted, but the attendants are in a great meafure fecu- red againft infection, if I may judge from a strict attention to this point, now of feveral years continuance. It is true an inquiry into this fubject is not without difficulty. The period during which the infection of fever may lie dormant in the fyftem without its being perceived in its effects is undecided. The obfervations of Dr. Haygarth on this fubject are however of great weight, and indicate that this period extends to eight or ten days, or even more. Ad- mitting then that the ablution of a patient under fever may be a means of fafety to the attendants, it cannot prevent infection from manifesting itfelf that has been received be- fore the ablution was performed; and if infection may lie eight or ten days dormant, fevers appearing within that fpace of time, after the firft employment of ablution, ought to be referred to infection previoufly received. If the truth of thefe premifes may be affumed, my experience testifies ftrongly in favour of the ufe of ablution, as a means of preventing the propagation of contagion. I have known a fever to fpread after ablution had been repeatedly and ef- fectually performed on the existing cafes of the difeafe, but in every inftance, I think, within ten days after this had begun to be practiced. To arrive at certainty on this im- portant point, will require numerous obfervations; but we cannot err in inferring, that among the means of preventing the propagation of contagion, general ablution of perfons labouring under the contagious difeafe, is one of the moft effectual. Though a fever not being fufpected may in the firft in- ftance be for many days overlooked, yet where its exiftence is once afcertained, vigilance will be excited, and future inftances of its occurrence detected earlier. In fuch cafes it is that the cold affufion appears to the greateft advan- * For the precife meaning of thefe terms, fee p. 66, vol. i. 256 tage. I might illuftrate this by a great variety of exam- ples, but the following fhall fuffice. In the month of Auguft, 1799, a warehoufe-man, in the fervice of Meffrs. Hodfon and Carter, of Liverpool, was affected with the low contagious fever, of which he died. I did not vifit him and cannot mention the parti- culars of his cafe. The difeafe fpread among feveral of the perfons round him, and among others, Mr. Bourne, a clerk in the houfe, who had been frequently with the ware- houfe-man, caught the infection. He was attended by Mr. Ellifon, by whom my afliftance was requested on the 12th or 13th day of the difeafe. The situation of Mr. B, was at this time deplorable. He was funk down in bed in the low delirium, infenfible to furrounding objects. His pulfe was feeble, and frequent almoft beyond calculation; petechias covered his body; he was affected with diarrhoea, and paffed his urine and (tools involuntarily. I lhould have confidered his cafe as defperate, had it not been that his refpiration was tolerably free, that his deglutition, though impaired, was ftill equal to the purpofes of nutrition, and that his heat was fteadily and confiderably greater than natural. As his ftrength did not admit of his being taken out of bed, the furface of his body was wafhed by means of tow- els dipped in cold vinegar and water. An anodyne abfor- bent mixture was directed to be given from time to time, to flop the diarrhoea and procure fleep. Yeaft, to the quantity of a pint daily, was alfo prefcribed, with broth, and gruel mixed with wine, for his food. On the fame day his mother arrived from a diftance to take charge of her fon, a woman of the strongest affections, but regulated by a correfponding ftrength of mind. She attended him night and day, forthwith, and implicitly followed our di- rections. Mr. B. lay on his back, fometimes in a difturbed num- ber, and fometimes with his eyes open, muttering to him- felf, and under the influence of fubfultus tendinum. His heat, though always greater than natural, varied in degree from time to time, as often occurs on the approach of 257 death, the exacerbations of heat being distinctly marked by a deep fluih extending over his face and neck. On every appearance of this fymptom, his mother was direct- ed to repeat the ablution of his body with vinegar and water. The ablution was performed from eight to ten times in the twenty-four hours, and was always followed by abatement of febrile agitation, and generally by fleep. The other directions were followed strictly. In forty-eight hours a dawn of recollection appeared, and the involuntary difcharges ceafed. In eight days more his recovery was as- certained. Mr. Hodfon had alfo very humanely vifited the ware- houfe-man, and been frequent in his vifits to Mr. Bourne. He was feized with fever, but did not at firft fufpect the nature of his illnefs, and I was not defired to vifit him till the fifth day of the difeafe. He was immediately subjected to the cold affufion, which was repeated in the evening. This was continued twice a day, the temperature of the water being raifed, firft to cool and then to tepid, as his heat diminifhed. He took faline draughts in the day, with an anodyne at night, and lived chiefly on milk and gruel. There was an abatement of his fymptoms. immediately, and in four days nothing remained but debility. Soon after, Mr. Bouker, alfo a clerk in the houfe, who had been expofed in the fame manner to the contagion, was taken ill. I faw him in thirty-four hours from the firft attack. His heat was 105 deg. of Fahrenheit, his pulfe ftrong and 120 in the minute, and fevere pains af- fected his head and back. We thew over his naked body fix gallons of water of the temperature of 60 deg. of.Fah- renheit in two fucceflive buckets, and replaced him in bed. His pains vanifhed ; his heat and pulfe fell to the natural standard ; he funk into a natural fleep, with a breathing moifture over his furface, and awoke in the morning free of every complaint excepting a flight languor. The fame fymptoms occurred in another cafe similarly situated, and were carried off precifely by the fame means. Mrs. Bourne herfelf efcaped. Her fon had been effectually wafhed before fhe faw him. 3" 2S8 The great debiljty of Mr. Bourne prevented us from taking him out of be.! for the purpofe of ufing the affufion. When the morbid heat has continued, and the ftrength has admitted it, I have often, in the laft four years, ufed the cold affufion even later in the difeafe than the period of it, when I firft faw him. In the cafe of a fervant of Mrs. Hf ywood, daughter of my refpected friend Dr. Percival, I ufed it on the 14th day of fever, with the immediate re- moval of delirium, and every other defired effect. Few accurate obfervations have been made of the effefts produced on perfons under fever, by expofure of their naked bodies to a ftream of air. The following may there- fore deferve to be recorded : In the month of May, 1801, I was defired to vifit a pa- tient ill of fever in Sparling-street. I found him in the tenth or eleventh day of the difeafe, delirious and reftlefs; the furface Of his body dry, and his heat 104 deg. of Fah- renheit. The room was clofe, and I defired the only win- dow in it to be opened. The wind from the north-weft blew directly into this window, and the bed being situated between it and' the chimney, a pretty brifk ftream of air paffed over it. The patient had juft thrown off a confide- rable part of his bed-clothes, and was expofed naked to the breeze. I fat by him, with my finger oh his pulfe, watch- ing the effect. In a little while the pulfe fell from 120 to 114 in the minute; he became more tranquil, and foon af- terwards he funk into a quiet fleep, in which he remained when the water for affufion was prepared ; of courfe we did not difturb him. When I left him, I defired the attend- ants :o fuffer him to remain in this fituation all night, un- lefs he became cold ; but to take care to adminifter the proper nourifhment. Once or twice in the night the attendants placed the bed- clothes on him, but he foon became hot and reftlefs, and they took them off again. While nuked he flept tranquil- ly, and had generally a gentle moifture on his fkin. In the morning I found him perfectly collected, and conside- rably refrefhed; his pulfe about 100, and his heat 101 deg. He coughed, however, a little, and we covered him with 259 a ftieet, which he now found agreeable to his feelings. The cough produced no ferious inconvenience, and in a few days the patient recovered under the common treatment. At the time this experiment commenced, the mercury in my thermometer ftood at 65 deg. and it did not fink lower than 63 deg. during the night. No certain inference can'be drawn from the refult of a fingle obfervation of this kind, but it is not to be doubted, that by a due attention to the heat of the patient, and his fenfations of heat, fuch obfervations might be fafely multiplied, and certain princi- ples at length eftablifhed refpecting the ufe of cold air as a remedy in fever. In the warmer regions of the earth, where the heat in febrile difeafes is probably greater than in our ifland, and the temperature of the atmofphere higher, a ftill more free admiffion of the wind to the naked body may of- ten be ufeful. The benefit which Dr. Jackfon and others have afcribed to geftation or travelling, in certain inftances, in the fevers of St, Domingo and America, is probably to be attributed in part to the mode of conveyance in open vehicles, in which the fick were probably little fatigued by the motion, and were invigorated and cooled by a conftant change of air, by fhowers of rain, and by heavy dews in the night.* In the fevers of this country, I have uniformly found fatigue to be injurious, and thofe who have struggled with rhem in the early ftages, to have a lefs favourable chance in the iffue. It has alfo happened to me to fte, in every inftance in which 1 have had an opportunity of ob- fervation, unfavourable effects in fever, from the ufual mode of travelling in a poft-chaife or clofe carriage, of fome of which I fhall prefently have occafion to fpeak. To the invigorating effect of the wind, and the coolnefs, and refreshment of the dews and the rain, 1 am alfo difr pofed to afcribe the fingular recovery, from the worst fpe*- cies of plague, mentioned by Defgencttes, in his Hiftoire Medicale de V Armee d'Orknt, p. 249. " A miner", fays * Thefe circumftances combined in the decifive examples given by Dr. Jack- fon, of the benefit of gtftation. Remarks on the Conftitution of the Medical Department of the Britifb Army, p. 296 and 297- I q«°«e D";- Ja«M'« narrative of tads with confidence. His inferences, general fpeculations, and jiraflical maxims, are lo much at variance with mine, lhat I have thought it a Jiopelefs taflc to attempt to reconcile them. 260 he, " attacked by the plague, during the expedition into " Syria, efcaped naked, during a violent delirium, from the " fort of Cathieth, and wandered nearly three weeks in the " defert. Two buboes which he had upon him at the time, " suppurated and healed of themfelves. He ate when hun- " grv> a ftp all fpecies of forrel, formerly defcribed." This man perfectly recovered. I have fuppofed him. to have been cooled by the rains as well as dews; for it appears, that during the period of his wandering, the French troops met with heavy rains in the progrefs of their march, of which in all probability he felt the influence. Having quoted the work of M. Defgenettes, I cannot forbear to extract the other remarkable recovery, from the worft fpe- cies of the plague, which he details. u An artilleryman, fC who had two buboes and an anthrax, (charbon) made " his efcape from the Lazaretto of Boulak, on the day of " his being admittec), and in a violent delirium precipita- i. Fother- gill himfelf, became doubtful of the beneficial tfLcts of baik in this difeafe. 283 affufion, according to the degree of heat and the ftages of the difeafe, with very general fuccefs. I was fully pre- pared therefore for the treatment of the wide-fpreading and fatal epidemic which broke out the latter end of the fum- mer of 1801. My family was at that time in the country, where it was feldom in my power to visit them. The fcar- let fever had appeared among the children in their vicinity, and carried off feveral. My two youngest children who had not had the difeafe, both boys, one five, and the other three years of age, had been in company with fome of thefe children at play, and had been expofed to the contagion. I gave directions that they lhould be watched narrowly, and that I fhould have intimation of the firft appearance of complaint. On the morning of the fifteenth of Auguft, a meiTage was fent me, that the eldest of the two had been reft- lefs and uneafy in the night, with feverifh chills, and pain in his head and back. I faw him in feven hours from the firft of thefe chills: he was then becoming hot, and had vomited up his tea: his face and neck were beginning to flufh, and it was evident that he was attacked by Scarla- tina. His younger brother had conftantly flept in the fame bed with him; though then walking about, he was evi- dently fpiritlefs and languid, and there was little doubt that he had alfo had caught the difeafe. In a little while the eldest boy became very hot, and the youngest fick and reftlefs. He followed his brother, ftep by ftep, at the diftance of about feven hours. The heat of the eldest foon raifed the mercury of the thermometer to 196 deg, 107 deg, and 108 deg, and in both, the fymptoms prognosticated a violent difeafe. I had loft a girl of four years of age in Scarlatina a few years before, though her firft fymptoms were far lefs violent; fhe periflied in confequence of the ulcerations extending to the epiglottis and larynx, and pro- ducing the fymptoms of genuine croup. I fhut myfelf up with thefe boys; and with plenty of pump water and a pocket thermometer, prepared, not without anxiety, to combat this formidable difeafe. It would be tedious and ufelefs to go into details. As foon as the fenfation of heat was fteady in my eldest boy, I ftripped him naked, and poured four gallons of water over him, of the temperature 284 of 64 deg. The ufual good effeas immediately appeared, but at the end of two hours he was as hot as ever—the re- medy was again applied, and repeated as the return of heat indicated. By the time the eldest was ready for his third affufion the youngeft was ready for his firft. The heat rofe in the eldest to 109 deg. in the youngeft to 108 deg. and the pulfe in each was upwards of 150. In thirty-two hours the firft had the gffufion fourteen times; eight times cold, twice cool, and four times tepid. Twelve affufions fufficed in the cafe of the youngeft, of which feven were cold. The fever was in both completely fubdued. On the morn- ing of the third day they were both evidently fafe; and on the morning of the fourth, though the pulfe was ftill a lit- tle more frequent than natural, they were both convalef- cent. In this ftate they inclined to fleep and reft. The fcarf-fkin peeled off them both and each had a flight degree of fwelling in the hands, but none of the other fecondary fymptoms. I might multiply thefe details, for the epidemic of that feafon would afford me ample fcope; but this would be tedious and unneceffary—One other narrative, illuftrative of the effeas of the affufion in different ftages of the dif- eafe, fhall therefore fuffice. In the fame month, (Auguft, 1801), the Scarlatina ap- peared in a back court out of Peter-ftreet, which contained eight fmall houfes, and forty-eight inhabitants, twenty-fix of which were children.* The two firft that were affefted, died; feveral others were taken ill, and consternation feized the reft of this little community. It happened that Mr. Barr, foreman in Mr. M'Creery's printing-office, lived in this court, and that two of his children were affeaed by the difeafe. He applied for my affiftance, and I under- took of courfe to give it the others alfo. I found nine children in different ftages of Scarlatina, but all admitting * For a defcription of thefe Courts, fee /. 231, vol. i. The particular court mentioned above, communicates with the ftreet by a covered paffage, 26 feet long, and only 2 feet 10 inches wide, and this is the only exit or en- trance. The court itfelf is 54 feet long, and 7 feet 10 inches broad, and con- tains eight fm ill houfes, four on each fid*, the deors of which front each other, and open into the court. 28S of the ufe of affufion, cold or tepid. I had not the (lightest difficulty in perfuading their parents to ufe it; they all followed implicitly the example of Mr. Barr. The mode of applying it was simple enough. The weather was warm, and the patients were brought out into the middle of the court, naked, where the water from the neighbouring pump was dafhed over them. As the heat declined, the water was made tepid. Not only was the affufion em- ployed for the fick, but once a day for the children in health alfo. It might ferve as a preventive, and at any rate it promoted cleanlinefs, which was enforced as effential —Ventilation was alfo promoted to the beft of our power. After this fyftem commenced, four or five others were feized with the Scarlatina, who all had the difeafe in the moft favourable way. Thofe in whom it was advanced, when I firft faw them, went through the fecondary fymp- toms—one of them with feverity ; but the whole recovered. No medicines were ufed, except a beverage of water aci- dulated with muriatic acid, an infufion of Cayenne pepper as a gargle, and calomel, where a cathartic was required— Milk, broth, and gruel formed the nourifhment. By thefe fimple, but powerful means, were death and difeafe banifhed out of thefe fequeftered families, and health reftored in fourteen or fifteen days. It is not a little curious, that ten children, all fufceptible of Scarlatina, lo far as was known efcaped it entirely. A circumftance occured during my attendance which deferves to be mentioned. One of the children, fuppofed to be taken ill of this difeafe, was uncommonly oppreffed in the firft ftages, and the heat much lower than in any other cafe. It varied from 99 deg. to 102 deg. No doubt however being entertained of the complaint, this child was fubjeaed to the cold affufion during the eruptive fever, in the fame manner as the others. But as the difeafe proceed- ed, it turned out to be the purple confluent fmall pox, and the patient died, as is ufual in fuch cafes, on the ele-1 venth day of the eruption.* • Mr. Barr, who is quoted in the courfe of the above narrative, is the perfon whofe hands are employed in fetting it far the prel's. (Firft edition). 286 A cafe nearly fimilar occurred in the prefent year. When the 24th regiment of foot was quartered here about ei^ht months ago, I wa3 defired by the affiftant furgeon to visit its hofpital.—Among other patients there was a young foldier juft brought in ; he had been affeaed by fever about twenty-four hours before, and was particularly opprefled in his head and ftomach, with violent pain in his back- he had fhivered and vomited feverely. On examining his heat, it was much lefs than ufually accompanies fuch fymptoms in fever,—There was a hoarfenefs in his voice and his face was a little fwelled, and darkly flufhed. I ad- vifed the tepid affufion, approaching to cool, which was feveral times repeated. The difeafe turned out to be the fmall-pox, of the purple confluent kind, and terminated fatally, notwithstanding every fupport from food or medi- cine. It appears then that there are cafes of fmall-pox, as well as of Scarlatina, which do not receive the ufual ad- vantage from the cold or tepid affufion, and that in the one difeafe as well as the other, there are cafes which fhow little morbid heat in the eruptive ftage, and in which great ma- lignity and putrefcence appear from the firft. To return to Scarlatina—this difeafe continued preva- lent during the autumn of 1801, and throughout the suc- ceeding winter and fpring; and though lefs frequent fince, it may be faid to have been conftantly prefent in Liverpool, in a greater or lefs degree, up to the prefent time. In all the cafes which I have feen during this period, amounting to upwards of a hundred and fifty, I have uniformly fol- lowed the praaice which I have juft defcribed, and with a degree of fuccefs fo nearly invariable, that I cannot con- template it without emotions of furprife, as well as offatis- faaion. In the courfe of this time, I have had occafion to combat the Scarlatina twice in public fchools, and in both inftances was completely fuccefsful, not merely in the recovery of my patients, but in ftopping the progrefs of the difeafe. The ufe of this remedy undoubtedly ftrengthens the confidence in the means of prevention, re- commended in the writings of Dr. Haygarth, Dr. Clark, and Dr. Blackburn, and now generally adopted by the fcientific part of our profeffion. I have received various 287 interefling communications refpeaing the fuccefs of this praaice in Scarlatina, from feveral of my medical friends, particularly Dr. Rutter, Mr. Dale, and Mr. Eaton, to which I would readily give a place here if my limits would admit. I cannot however refufe myfelf the pleafure of publifhing the following communication from Dr. Grego- ry, Profeffor of the praaice of Medicine in the Univerfity of Edinburgh, which reached me at the moment that this fheet was going to the prefs. The weight of fuch an au- thority will be duly appreciated by the world; and Dr. Gregory's evidence fhall be given in his own full, clear, and forcible language. " Edinburgh, 9th Nov. 1803. " Dear Sir, " It is to inform you of part of my family distress, and at the same time to thank you for a piece of very valuable prac- tical instruaion, which I received from you two years ago, indi- rectly, and at second hand, that I write to you at present. " You will remember that, about two years ago, you informed Dr. Wright * of the success which had attended your praftic.e of cold affusion, in fifty, out of fifty-two, cases of Scarlatina. Dr. Wright shewed me your letter, and as your observations appear- ed to me very interesting, I transcribed into one of my note books that part of your letter, verbatim, and have read it the two last winters in college, when treating of the Cynanche Maligna; tell- ing my pupils that I had no personal experience of the praaice, but that I thought your testimony in its favour, and the analogy of the good effeas of the very cold praaice in continued fever, and in natural small-pox, so strong, that I was resolved to try your prac- tice of the affusion of cold water in Scarlatina, the first good op- portunity; meaning the first recent, violent case, with great heat, and frequent strong pulse, that should come under my care. " It happened that I saw none but slight and very favourable cases of the disease till last August, when I was called to a# girl of thirteen, who had been ill of the Scarlatina, with a very bad sore throat, for near a week. She seemed to me very likelv to die, and in faa did die, in a few days. " I mentioned in consultation the cold praaice by affusion, but could not urge it, for two reasons; first, because the circumstan- " Dr. Wright with whofe important narra'ive this work commences. 288 ces of her disease seemed to me very unfavorable for it; the hot state of it was past, and the symptoms of debility, putrefaction, delirium, stupor, and even some watery bladders on the skin, (which I have very seldom seen), were come on. I could not expeft to save her by your practice, and I could easily foresee; that an unsuccessful use of it would have brought a reproach upon the praaice, and would have prevented it from being followed in other cases, in which it might probably have done good. In the second place the girl's own situation was so peculiar, * * * * that I was very unwilling, for moral and prudential reasons to try any new and rough praaice on her ; for if she had died under it, which most probably would have happened, it might have been said, that she was chosen as the subject of a severe and dangerous experiment, because she was a helpless, unproteaed orphan. So she had her chance by the best of all other means, that I knew of, for her relief, particularly bark, wine, acids, fruit, the cool regimen, great cleanliness, and ventilation ; and, at one tijpe, opiates and astringents, on account of colliquative diarrhoea; but all to no purpose. " The next patient in Scarlatina that I had occasion to see, was a nephew of my own, the eldest son of my deceased brother, a stout boy of fourteen, of the melancholic temperament. Whether he brought the contagion of it with him from England, whence he came in the beginning of Oaober, or whether he got the conta- gion in my brother-in-law's house, near Edinburgh, which I sus- pect: was the case, as the children of that family had had the dis- ease last winter, though in a very mild form, I know not; but soon after he arrived in Scotland, and in that house, he was at- tacked with Scarlatina. The case proved a pretty smart one, with ulcers in the throat, copious scarlet efflorescence, hot skin, and pulse 120; but as I saw no symptoms of danger in it, I did not urge the cold affusion, but told him, that if he grew worse he should be soused in the most complete manner. He recovered perfeaiy well, and soon, without it; and after much purification of himself, his clothes, and his baggage, was received into this house three weeks ago. "This day se'ennight, (1st Nov.), my eldest son, a boy of six years of age, of a sanguine temperament, and very irritable con- stitution, was taken ill about noon, when out at his walk. Your friend, Benjamin Bell, saw him before I did, for having called on me to speak about a patient, he inquired for my wife, and found the child with her, lying on a settee in her dressing room. She anxiously begged of him to examine the child, and see whe- ther he had got the scarlet fever, which, from the circumstances 289 already mentioned, she suspeaed might be the case. Mr. Bell had no difficulty in pronouncing at once that the disease was the scarlet fever; for even by that time, (within two hours from the invasion), the eruption of red prominent points was very copious, and evident, so as to give a general roughness and redness to the skin of his breast. In that state I found him soon a ter Mr Bell left him; his pulse frequent, and small, his skin but just beginning to grow hot, and his hands rather cold. He complained of gene- ral oppression, uneasiness, and head-ache. The velum pendulum, uvula, and tonsils, were of a dark purple red; but there were no ulcers or aphtha- on them, that I could see. Before six at night, he had much more severe head-ache and oppression, with nausea, vomiting, and diarrhoea; his pulse 140, and very strong, his skin very hot, and of a bright red, with a considerable roughness all over it. " Conceiving this to be a case of the most imminent danger, and, in every respea, proper for your cold praaice, I lost no time in getting him taken out of bed, stript, and set erea in a tub : in which situation, I poured a gardeners watering-pan full of cold water all over him, from head to foot. This relieved him a good deal; and, as you may believe, cooled him very effeaually: but before ten at night, the symptoms had recurred with more vio- lence than ever. His pulse was 160, and very strong, his face turgid, his eyes growing red, his skin very red from head to foot, and very hot. I did not take time to measure the heat of his skin by the thermometer; but I think it must have been at least 104 deg. of Fahrenheit. I immediately repeated the cold affusion as before, and with the same good effea. He was immediately cooled and refreshed; and half an hour after, I found his pu!se 120, and the heat of his skin very moderate. He had a pretty good night; but before eight next morning was become very hot again; on which account the affusion was repeated in the same manner. He said he did not like my way of bathing, and would rather be bathed in his own tub; and as I thought, from the state of the symptoms, that there was occasion for it, he was bathed in his own tub, and fairly laid under water, over head and ears, between eleven and twelve at noon, and again at six in the evening of the second day. " These five good sousings, in twenty-four hours, seemed to me to have done the business completely. The eruption was not repelled, but the progress of the local affeaion in the throat seemed to be stopped. I could never see any ulcerations in it, though I looked carefully for them, in consequence of having ob- served much foetor of his breath on the second evening. The for.ce 37 290 of the fever, as to heat and frequency, and strength of pulse, seemed to be quite broken after the fifth ducking; to such a de- gree even, that I began to have some fears that the vis vita might fail, and had aaually provided wine to be at hand, to give him from time to time, in case of need, and saw him several times during the night between the second and third day of his disease. But I found.no occasion to give him any of it; nor has he had a grain of medicine, or even a drop of wine during his illness; so that you must allow it has been a very fair experiment of the cold affusion, as a remedy for the scarlet fever. Indeed ever since the morning of the third day, (forty-three hours from the invasion of the fever), I have considered him as a convalescent, though he had occasionally, for three days afterwards, some transient quick- ness of pulse and heat of skin. His throat was quite well the morning of the fourth day; the same day he had some slight swelling of his hands; but not the twentieth part of what I have often seen after a severe attack of Scarlatina. He has had for some days, a kind of crick in his neck, or pain extending from his right ear towards the shoulder, which makes him carry his head awry, inclined to that side; and I can feel some of the lymphatic glands enlarge; but they are not bigger than large pin heads. He is losing his cuticle by desquamation, as was to be ex- peaed ; he has been washed with tepid water and soap for three or four nights, to promote that desquamation, and relieve the itching of his skin. He has not yet recovered his flesh, strength, or colour; but seems in a fair way to do it soon, for he has a keen appetite and digestion, and, for three or four days has been able to play as usual in his nursery; this being only the ninth day of his disease. " You may be sure, from this detail, that I am perfeaiy well pleased with your praaice in this disease: and that I shall gladly follow it in any proper cases of the same kind that may come un- der my care, if I am allowed to do so. I can now propose and urge the praaice with a good grace, and some confidence, after having tried it with success on a child of my own. It is more than possible that I shall soon have occasion to try it on two other sons of my own; one of them past four, the other of them almost two years of age, and both of them of the same sanguine temperament of their eldest brother. Both of these younger children were ex- posed to the contagion from their cousin, my nephew, as much as my eldest son was, and both of them were with him when he sickened, and for two hours after, so that I could have no hopes of completely preserving them from the contagion; I there- fore allow them to be fully exposed to it, by sleeping in the same ro6m with their elder brother, and playing with him whenever 291 he was able to play. The two younger children are also the sub- jeas of another experiment: both of them have had the cow-pox, which my eldest son has not. Him I had inoculated with the small-pox, many months before I ever heard of the cow-pox. " Thus far I had written, (Wednesday, Nov. 9th), and meant to have said that the experiment going on in my nursery, might help to ascertain the point, which I understand has been a matter of conjeaure and speculation, whether the cow-pox preserve those who have it from the scarlet fever, as it seems to do frdm the small-pox, and as it is said, from the plague. If my two younger children escaped it, when so completely exposed to the contagion, it would give some countenance to that favourable opinion with respea to the cow-pox; if either of them took the scarlet fever, it would effeaually put an end to that opinion; for major est vis instantia negative, in omni axiomate vero constituendo; but the expe- riment in that respea is already finished; and that point settled unfavorably for the cow-pox.* Yesterday afternoon, my youngest son sickened, and had the usual symptoms of oppression, sickness, vomiting, diarrhoea, frequent crying, frequent pulse, copious red eruption on the skin in less than three hours after he began to be uneasy, flushing of the face, and increase of heat: but neither the frequency of pulse, heat of skin, or flushing of the face, have been nearly so great as they were in his brother. I have not been able to see the inside of his throat, but as his voice is somewhat affeaed, and hoarse, I presume he has a slight degree of Cynanche; but he swallows both liquids and solids without difficulty, so that I have no great fears from the state of his throat. His eyes have been less red, but more watery, than his brother's were, and he has had a very copious salivation, which his brother had not. " Though he was never so hot as his brother, he was washed in a tub with cold water, about seven o'clock, and again about eleven, last night, and twice to-day already with tepid water, as he was still less hot than yesterday, and his feet even cool. He has been relieved by the washing all the four times, and has aways gone to sleep after it for a longer or a shorter time. At present I see no symptom of peculiar danger about him. " My other son, (the four-year old gentleman), has not yet sickened; but I expect him to be taken ill to-night or to-morrow: for last night he had very little sleep, and frequently through the night, and to-day, he has complained of being tired. Lassitudines spontanne morbos denunciant, is one of the oldest maxims that I know • The univcrfal adoption of the cow-pox in Liverpool, and the prevalence of Scarlatina, had decided this que. tion long ago theie. 292 of in physic, Whenever he s'.ckens, I mean to treat him as 1 haveu<.ue nis biothers. " i ins long and minute detail will perhaps not be altogether uninteresting to you, as the author of that praaice, which 1 have followed : but that I may follow it the more confidently in other cases, and be enabled to answer some of the many questions that will be put to me about it, I beg you will inform me, if you have made any other interesting observations respeaing it; and parti- cularly if you have observed any bad effeas, either immediately or remotely from it. How long have you observed the febrile state to continue after its force was broken by the cold affusion? Have you observed more or less of the anasarcous swellings of the extremities after this, than after the common praaice ? Have you observed after it any symptoms of ascites, or of hydrothorax, or any affeaion of the head, such as coma, delirium, or convulsions, or any parotids. Has the convalescence after this treatment been quicker or slower than usual ? " I trust I need make no apology for giving you all this trouble. *{ Your's most truly, ♦«J. GREGORY." To the queftions of Dr. Gregory I replied in courfe of poft. As however the anfwers given may be clearly infer- red from what I have already faid of the effeas of the afFu- fion applied early in preventing the fecondary fymptoms, it is unneceffary to infert my letter at length. 1 he refult of the whole was, that my experience afforded no giounds for any of the apprchenfions imp ied in the very judicious inq-ui.*ies which he had made. I concluded v\irh a requeft to be informed of the progrefs of the difeafe in his family. This was complied with in the following letter. "Edinburgh, 10th Nov. 1803. « Dear Sir, " I thank you for your kind attention in giving me such a full and speedy answer to my long letter. It is most completely satisfadtory to me in every respect; and I am sure it will give 370U satisfaaion to know that my children have all done very well, under your praaice for the Scarlatina. The eldest and youngest, though they have not yet fully recovered their strength, are re- covering it very fast, are in excellent spirits, and on the whole so well, that they have been out of doors repeatedly, both in the 293 carriage and on foot; though the weather has been very cold, even with frost and snow, for some days. Both of them have still some swelling of the lymphatic glands on both sides of the neck, extending from the ear almost down to the shoulder. This I think the more remarkable, as I could see no ulceration in the throat, and no particular cutaneous affeaion on the hairy scalp of either of them. ^The swelled glands are no longer painful, and are already growing smaller and softer: so, I presume, they will discuss completely without any difficulty. " The extraordinary salivation which the youngest child had, was soon and completely explained. It appeared that the scarlet fever had brought on, or at least accelerated, a fit of teething, and that two new teeth were just cutting the gum: they are now quite through, and of course he is perfeaiy at ease : but, for four or five days alter the Scarlatina was subdued, he seemed to suffer more from the irritation of teething, than he had done from that often severe and dangerous fever. "The four-year-old gentleman whom you inquire after, sick- ened on Monday morning, 14th November, or sometime in the night between the 13th and 14th. He had been complaining for five days, much and frequently, both day and night, of being tired; at day break on Monday he complained much of head-ache, and, upon looking at his skin, he was found to be from head to foot, as red as a boiled lobster. His pulse for two days, was near- ly as quick as his elder brother's had been, (from 130 to 150), but it was not nearly so strong, nor was his skin ever so hot as his el- der brother's had been. The eruption still remains very copious. (Thursday afternoon, the fourth day of his disease). There was very little redness, no dark purple colour, and no ulcers in his throat, which I have seen, well, and repeatedly every day. He had no vomiting or diarrhoea, as both the others had ; but his body-continued quite open as in his perfea health. Supposing the head ache, which in him was very severe, to proceed from the stomach or bowels, being in some measure loaded, I gave him on the afternoon of the second day, three grains of calomel, which did not operate as a purge, but soon, and very effeaually a* an emetic ; and seemed to remove his head-ache; but as this return- ed on the morning of the third day, after being suspended for about sixteen hours, two good leeches were applied to his temples, by which he lost a good deal of blood, with great and immediate relief to the head-ache; which has not yet returned, and I pre- sume, never will return. " The cure in this boy, as in the other two, was trusted to the washing; but as his^ pulse was not very strong, nor his heat very 294 great, the Water «was not perfeaiy cold, though very gently tepid; so little warm as to make him shiver. It seems to have succeeded as well with him as with either of his brothers : the heat of his skin, which is still red, is little more than natural; his pulse is come down to 108, he has eat his dinner to-day with a good ap. petite, and about an hour ago I saw him walking, or rather stag- gering about his room ; but I presume he wouU soon tire of that, and go to bed again, as he is still weak. I concede him to be a fair convalescent. " I have had much pleasure in observing repeatedly in the youngest child, (the two year-old-gentleman), the great and imme- diate good effeas of the cold or tepid washing, not only in les- sening the frequency of pulse and heat of skin, but in relieving the febrile oppression and uneasiness. The little patient who just before was crying very much, unable to hold up its head, incapable of being pleased or amused with any thing, nay al- most incapable of looking at any thing, immediately after be- ing washed, (I mean in two or three minutes), would begin to look up, and take notice of the people near him, then amuse himself with his playthings, then get upon his legs and run about upon the floor, and at last go quietly to sleep. " From what you mention in your letter, I am sure such obser- vations must have been quite familiar to you. " Your's most truly, «J. GREGORY." To comment on cafes related with fuch circumftantiality and precifion, would be to weaken their effea, and with this fingle obfervation, that I fufpecl the heat in the firft of Dr. Gregory's cafes to have been feveral degrees higher than he fuppofed, I leave this interefting narrative to the refieaions of the reader. Before I conclude the fubjea of Scarlatina, I muftup enforce the fuperior advantage of ufing the affufion early in this difeafe ; and the propriety of afcertaining that the fkin is dry, and the heat of the patient greater than natural, in all cafes, efpecially in fuch as are advanced, and where, of courfe, the ftrength is confiderably impaired. It has come to my knowledge, that in two cafes of Scarlatina, of the moft malignant nature, the patients have been taken out of bed, under the low delirium, with the 295 fkin cool and moift, and the pulfe fcarcely perceptible. In this ftate, fupported by the attendants, feveral gallons of perfeaiy cold water were madly poured over them, on the fuppofed authority of this work ! I need fcarcely add, that the effeas were almoft immediately fatal. It has happened in feveral inftances, that the cold, cool, and tepid affufion, have been ufed in the early ftages of the Cynanche Tonsillaris, or common inflammatory fore throat. Though I fhould not have ufed it in fuch cafes by defign, I never found injury to arife from it. On the contrary, .it was uniformly followed by a mild difeafe. I fhould have been ftill lefs inclined to have prefcribed it intentionally in the meafles, on account of the difpofition to pulmonary affeaion which attends that difeafe. It has happened to me, however, to have direaed it four differ- ent times by miftake, in the eruptive ftage of meafles, and in like manner, the difeafe that followed was fingularly mild in every inftance. When the Influenza was prevalent laft fpring, I did not employ the affufion on account of the cough and pulmo- nary fymptoms which attended that difeafe. I contented myfelf with diaphoretics, blifters, and diluents. My pa- dens recovered under this treatment, though in fome in- ftances, flowly, and with difficulty; efpecially in cafes where there had been a previous afthmatic or confumptive tendency. Though conftantly expofed to this difeafe, I efcaped for nearly two months; but at length was feized by it feverely in the beginning of May. Being of a phthifi- cal conftitution I was not without anxiety as to the debility it might induce, or the pulmonary affeaions it might leave behind ; and refkaing on the remedies I had employed, it did not appear to me that any of them had materially fhort- ened the difeafe. I determined therefore to try the tepid affufion, approaching to cool, and fubjeaed myfelf to the fhower bath every three or four hours regularly, at. the temperature of 85 deg. The effeas were in a high degree grateful, foothing, and invigorating. I fuffered nothing from pulmonary affeaion, either during or after the dif- eafe. The debilitv went off verv foon, and I recovered 296 more fpeedily than any of my patients. The great pecu- liarity of the Influenza feemed to be the fpeedy debility which it induced, and the morbid fenfibility of. the nervous fyftem by which it was accompanied. The heat in this difeafe was not great. It varied from 99 deg. to 101 deg. and 102 deg. which is pretty nearly the temperature of meafles. Though I attended to the fubjedt, 1 am at a lofs to decide whether the Influenza was contagious or not. If contagious, it fpreads by laws peculiar to itfelf. It will be proper to fay a few words of the affufion of warm uater on the furface of rhe body; that is water of the temperature of the blood, and upwards. This produces a very confiderable fenfation, of a highly grateful nature, but is followed by a great degree of chiilinrfs, and fome- times by pulmonary affeaions in perfons difpofed to them; in others by catarrhal affeaions, and the other fymptoms which indicate what is meant by the common expreffion of having caught cold. I have ufed it chiefly in maniacal af- feaions, and fometimes in them with foothing effeas. That it produces a powerful influence on the fyftem of fenfation, the following cafe will fhew. H. D. a young man in an apothecary's fhop in this town, intending $0 take an ounce of tinaure of rhubarb, fwallowed by miftake an ounce of laudanum. He imme- diately perceived his error, and took as quickly as he could, but not till two minutes had elapfed, three grains of tartanzed antimony, attempting at the fame time to bring on vomiting, by irritating the internal fauces. Find- ing his efforts unfuccefsful, he took almoft immediately fix grains more, and a fudden terror feizing him, frdrn perceiving the effeas of the laudanum, he left the fhop, and ran as faff, as poflible to my houfe, (a diftance of about three hundred yards), for further affiftance. I was fitting in my ftudy, when I heard a furious ring at the outer door, which was inftantly opened, and the young man ruihed in upon me, with marks of the greateft agitation. Before he had time to fpeak, vomicing came upon him, and learning the circumftanc s of the cafe from the mafter of the fhop, who followed clofe after, I encouraged the vo- 297 miting by warm water, and inceffant irritation of the fau» ces. Experience had taught me that there is no fafety without keeping up vomiting for a confider ible time, and it was continued for half an hour or upwards, at the end of which time the ftomach became unirritable, and debility and ftupor increafed upon him. He however contrived to walk home with confiderable difficulty, fupported all the way. When laid upon a fettee, his eyes appeared fuffufed and heavy; his pulfe was 95, and rather feeble; and drowfi- nefs, notwithstanding conftant external impreffion, was faff gaining ground. In this ftate, I direaed feveral gallons of warm water to be poured on his naked body, which had the fingular effect of removing entirely the drowfinefs for about ten minutes; but it returned again, and he could fcarcely be kept awake by conftant ihaking. This agita- tion however brought back the vomiting, and he threw up the vegetable acid which had been direaed for him. The warm affufion was repeated a fecond time, with the fame effeas a* at firft. The tongue foon af^er looked whit*, the fkin grew hot, and the pulfe rofe to 105. The warm affufion was repeated a third and laft time; imme- diately after which, a very cold fit took place, with great tremor and faintnefs. He was put into a warm bed, and allowed to fleep, but the difpofition to it was gone ; about nine hours after the accident, he was able to take fago, and fell afleep. In this ftate he continued through the fuc- ceeding night, and awoke in the morning languid, but refrefhed and free of all complaint. I give this cafe chiefly from the notes of the gentleman affeaed. The ufe of warm water was in the firft inftance acci- dental in this cafe—I had ordered the tepid affufion; but obferving the water to be very warm, (probably 106 deg. or 108 deg.), as it flowed over him, and that a great effect was produced, it was continued of nearly the fame temperature. 38 298 CHAP. 111. Communications to the Author refpetling the Ufe of the Cold and Tepid Affufion in different Parts of Great Britain. BEFORE I prefentcd to the world an account of the ufe of water externally and internally, as a remedy in fever, I had witneffed its effeas for a period of ten years, and for five years of that time, in hofpital praaice, un- der circumftances moft favourable to accurate obferva- tion. By this means, in announcing the remedy, I was enabled to lay down certain rules for its adminiftration, which, if not perfea, were however fafe; and I had it in my power to exhibit its effeas, on fo large and fo varied a fcale of obfervation, as to render it improbable that the reiults could be fubftantially erroneous, though they might not be precifely correa. My publication was favourably received at home, and the fecond edition tranflated. into the French and German languages. The progrefs of the praaice it recommends has been as rapid as I could have hoped, or perhaps wiflied ; for it was not my defire that it fhould be embraced with the vehemence of enthufiafm, but that it fhould be received after flow and cautious in- veftigation ; and it was impoffible for me not to deprecate its being employed at all by thofe praaitioners whofe cha- raaer of mind, and habits of life, rendered them impatient at the clofe, and fometimes painful attention neceffary to the adminiftration of fuch powerful remedies. In the fpace of fix years this pradice has however made confiderable progrefs through the ifland ; there are few parts of it in which it is unknown, and there are fome in which it may be* confidered as fairly eftablifhed. In London I have reafon to believe, that it is now ma- king fome progrefs,* and its fuccefs under the direaion of * See the paper of Mr. Blegborough, in vol. viii. p. 158, of the Medical and Phyljcai Journal, and that of Mr. Pearfon, in the fame volume, p. 357. 299 Dr. Dimfdale, in the hofpital for fever, denominated the Houfe of Recovery, is fo ftriking, that though the account of it is already given to the world, I think it proper to infert it here. Extract from an Account of Cases of Typhus Fever, in which the Atfusion of Cold Water has been applied in the London House of Recovery. By W. P. Dimsdale, M. D. CASE I. "James Johnson, aged eight years, caught the infeaion from his parents, who died of fever. He was removed on the 19th May, 1802, into the Hduse of Recovery. On the 23d of May, (the twelfth day of the disease), the symptoms were as follow:— pulse extremely frequent; tongue covered with a dark fur, and very dry; skin dry. A thermometer placed under the tongue arose to 104- deg : constant and violent delirium. The usual me- dical treatment not being attended with success, recourse was had to the affusion of cold water. He was taken out of bed, strip- ped, and a pitcher of cold water was poured suddenly over him: after being wiped, he was replaced in bed." He slept an hour; the skin felt more relaxed; no perspiration however followed. May 24th, pulse 120; skin dry; heat 100deg; delirium conti- nues ; no sleep in the night. The affusion was repeated with a pail of cold water. He again slept quietly, was evidently more colleaed when he awoke; and soon afterwards a profuse perspi- ration came on, which continued through the night. On May 27th, (the fourth day after the cold affusion had been first used), he was entirely free from fever. CASE II. "Thomas Knight, aged twelve years, was admitted June 16th, on the fifth or sixth day of typhus. In the afternoon, pulse 116; skin dry, with numerous petechia:; heat 104 deg; eyes suffused; violent pain of the head. The cold affusion, w,ith a pail of water, was direaed. The pain of the head subsided, he slept quietly, and copious perspiration, followed. From this time the symptoms were favourable. On the 22d he was free from the disease, on the fourth day after he was removed from the house. 300 CASE III, " John Harrogan, aged twenty-six years, came into the house on July 8th, the fifth day of the disease: pulse 120: tongue fur- red and dry; skin hot and partially moist ; delirious at intervals; pain of the head and back. July 9th, violent delirium came on in the night, two nurses were unable to keep him in bed. t The matron of the, house sent for me at five o'clock this morning: he was then extremely outrageous ; pulse 136 \ skin hot and parch- ed. He was placed by force under the shower-bath, and two pails of cold water were poured instantly over him. The transition from a state of extreme fury, to perfea calmness, was truly sur- prising. Without an effort of resistance on his part, he was re- placed in bed : profuse perspiration succeeded. In three days he had no symptom of fever remaining. CASE IV. "Alfred Sweeting, aged four years, was removed into the House, 13th July : he caught the infeaion from his mother, who died in a small and dirty apartment. Oq July 15tb, fourth day of the disease, pulse very frequent, skin dry, heat 102 degrees; tongue slightly furred, countenance expressive of much uneasi- ness. The shower-bath was used : he appeared immediately to be much relieved; general moisture of the skin followed. On the 16th he was free from fever. This patient took only the sa- line mixture, and afterwards small doses of the diluted nitrous acid. CASE V. " Henry Hancock, aged twenty-eight years, was on the tenth of August, the fifth day of typhus,' removed into the house. Pulse 120; tongue furred, slightly moist; skin very dry ; heat 105deg; severe pain of the head. The shower-bath w,as direct- ed. The pain of the head was removed instantly; perspiration succeeded. The symptoms continued favourable to the 14th, when he had no coniplaint remaining except weakness. CASE VI. • " George Johnson, aged fifteeji years, came in on the 13th of August. On the 14th, (fifth day of typhus), pulse 124, heat 91! 301 deg, slight partial moisture of the skin: the tongue furred, and much general uneasiness. August 15th, he has been very deli- rious in the night, and extremely restless: complains of violent paid of the head ; pulse very frequent, tongue furred, rather dry; skin dry, numerous petechia over the body; heat 103 degrees. The shower-bath was immediately used. The pain of the head was instantly removed, but no general perspiration followed. In the evening the head-ache and the other febrile symptoms return- ed with nearly the same severity as before. The cold affusion was again used, and he felt immediate relief. Copious perspira- tion very soon succeeded, which continued through the night. He was free from complaint on the 17th, the third day after the first use of the cold affusion. CASE VII. " John Beard, a boy aged eleven years, was admitted on the 21st of August, in the third day of fever, with the usual symp- toms : pulse frequent; much thirst; pains of the head and back; the skin rather moist. 22d, skin dry, heat 103 deg, pulse 116, tongue furred; pain of the head continues. The cold affusion was direaed immediately, and applied again in the evening. He passed the night easily, the skin was partially moist: he had some refreshing sleep. August 23d, the skin is now dry; heat 104 deg; complains as before of much pain and general uneasiness. He again used the shower-bath. In the evening, the skin being dry, and the heat 102 deg; it was repeated : profuse perspiration came on in the night. 24th, skin very moist; heat 98 degrees; pulse 100; tongue slightly furred ; says he feels much better : In the evening, during a short absence of the nurse, feeling a slight return of heat and uneasiness, he poured a pitcher of cold water which was in the room over himself into the bed. The nurse returning immediately, she removed him to a dry bed : he slept quietly through the night, the skin moist, and awoke in the morning quite free from fever. The only medicines ordered in this case, were the saline mixture, and small doses of Colombo. CASE VIII. " Abraham Johnson, aged twenty years; was admitted on the 6th of September, with the usual symptoms, in the fifth day of fever. Sept. 7th, skin dry; heat 100 deg. The shower-bath was used, which produced considerable relief. On the 9th the. 302 heat was again 100 deg. the skin dry. The cold affusion was re- peated. He was free from fever on the 12th. CASE IX. » Mary Johnson, aged eleven years; removed into the house August 13th, in a late period of fever. She relapsed August 22d. On the 23d, pulse 132: tongue covered with a dark fur, rather dry; skin dry, heat 103 deg. pain of head and back. Copious perspiration succeeded the cold affusion, and in two days she was entirely free from fever. CASE X. " Robert Holmes, aged twenty-six years; admitted September 7th, with fever of uncertain date. Pulse 100, tongue slightly furred ; pain all over the body. In the evening the skin became very dry; heat 100 deg. A slight delirium with which he was affeaed, subsided immediately on the use of the shower-bath. He was free from fever on the 10th, but extremely feeble. By'the use of a nourishing diet, and small doses of the bark and wine, he gradually regained his former strength. QASE XI. " John Dutchfield, aged twenty-one years; admitted on the 25th of September, with the usual symptoms of fever. On the 28th, (ninth day of the disease), skin dry, heat 100 deg. used the shower bath; the heat diminished, the skin became moist, On the 2d of Oaober he was free from fever. CASE XII. " Mary Simmons, aged forty-two years, was admitted Novem- ber 18rh into the house, with the usual symptoms of fever ; the date uncertain. On the 20th, pain of the head'exceedingly vio- lent ; skin dry; heat 99i. deg. The head-ache ceased immediate- ly after the cold affusion, the skin became rather moist. On the 23d, the heat again rose to 99£ deg. the skin dry; copious per- spiration followed a repetition of the affusion. She was free from fever on the 25th. 3°3 " OBSERVATIONS. " It appears unnecessary to relate the other cases in which the cold affusion had been used. In all, the good effeas of it have been strikingly manifest, and in no instance has the disease ter- minated fatally after the use of this remedy. In the early stages of typhus the affusion, with very little assistance from medicine, appears to cut short the progress of the disease. In the more advanced periods, when the strength of the patient is sufficient to admit the application of this remedy, it moderates the violence "of the symptoms, and contributes materially towards a favourable termination. When the strength is greatly exhausted, it may probably be wholly inadmissible. The patients almost invariably expressed great satisfaaion, after the agitation immediately fol- lowing the affusion had subsided. The violent pain of the head, so distressing in fever, is almost constantly and immediately re- moved, and generally, quiet sleep succeeds, with moisture of the skin. " Case the 7th furnishes a strong illustration of these remarks. The boy always after the first affusion, went to the bath with perfea readiness, and even solicited its repetition. The almost immediate discovery of the affusion which he had himself prac- tised, prevented any injurious consequences; and it is evident from the report of the following day, that the slight exacerbation of fever which came on in the evening, was completely removed by this application. The feelings of the patient in this instance immediately prompted him to have recourse to the remedy, from which he had before experienced so much relief.* " Spring water has been used hitherto without any addition. A shower-bath is placed in the House of Recovery for the purpose of applying the remedy. It is obvious that the affusion is by this means rendered more complete than by any other mode of appli- cation ; it is also nep.ter, and more commodious. Ablution of the body, by sponging with cold or tepid water and vinegar, has been frequently employed with advantage: it is however less effe-aual than the affusion. " I shall feel peculiar gratification if this short account, by con- firming the faas stated in the elegant and truly valuable publica- tion of Dr. Currie, should tend to accelerate the general intro- * " The reader who is defirous of information as to the ufe of the cold affufion (or of the tepid 'bath) in cafes of fcarlet fever, is referred to Dr. Currie's Medical Reports, p. 287 and 288 ; aud to fome other parts of that f-xccllent work."—Dr. Dimfdale-----Set in this vol. chap. ii. J. C. 3°4 duftion of a remedy so important in the treatment of fever; being fully convinced from the uniform success which has attended the practice, that it may be used with perfea safety in this disease, " when (to use Dr. Currie's words,) there is no sense of chilliness " present, when the heat of the surface is steadily above what is " natural, and when there is no general or profuse perspiration." 5th January, 1803. This account was obligingly communicated to me by Dr. Dimfdale on its firft publication. Four months after I wrote to inquire the refult of his farther experience, and received the moft fatisfaaory reply. It had, during that time, been ufed very extenfively, and except, in two in- ftances, with invariable fuccefs. The two patients who died, he obferves, were both admitted on the feventh day of fever ; no remedy had been employed previoufly to their admiffion, and the cafes were fo extremely violent and irregular, that they appeared to be nearly hopelefs. The cold affufion relieved the more violent fymptoms tempo- rarily, but did not prevent the fatal termination of the fever. He adds, that from a comparifon of thefe with other cafes which have occurred in the Houfe of Recovery, it may be fairly prefumed that the remedy would have been effeaual in an earlier ftage of the difeafe. At Edinburgh, the metropolis of the northern divifion of the ifland, ablution of the furface in fever has been praaifed for feveral years with great advantage by Dr. Gregory, and perhaps by others. During the winter 1802-3, the cold and tepid affufion were employed in fixty-four cafes of fever in the clinical ward of the Edin- burgh Infirmary, by my friend Dr. James Home, with extraordinary, I believe I may fay invariable fuccefs. In moft of thefe cafes the difeafe was fo far advanced, on ad- miffion, to allow of its being cut fhort; but in fueh cafes as prefented themfelves in the early ftages, and particularly in fome of the nurfes who caught the infeaion from the patients, its power of arrefting the fever was evident and ftriking. Dr. Reeve obferves, " the number of patients labouring under fever admitted laft winder into the clinical ward, was unufually great. In the treatment of thefe pa- tients, which was extremely judicious in every refpea, the 3°5 moft ftriking and marked advantages were derived from the affufion of cold and tepid water. To the manifeft in- fluence of thefe powerful agents, our clinical profeffor, Dr. Home, jun. attributed with great modefty, and apparently with great juftice, the very favourable termination of fo many and fuch dangerous cafes. As far as obfervation during three years will enable me to judge, the continued fevers of Edinburgh are generally attended with catarrhal fymptoms. In moft of the patients in the clinical ward laft winter, thefe fymptoms were ftrongly marked. In fome cafes the cough was fo violent as to require blifters, ^ and even blood-letting. The danger was ftill farther rn- * creafed in thefe inftances by violent head-ache, great prof- tration of ftrength, delirium, and petechias. The fkin in moft cafes was very hot and dry. The greateft degree of heat afcertained by the thermometer was 106 deg. in the cafe of a young girl. The moft important point, as you have juftly remarked in your Medical Reports, which re- quired to be eftablifhed by experience alone, was the fafety of employing the affufion in cafes of fever combined with fymptoms of local inflammation. Now the frequent trials made at Edinburgh afforded moft fatisfaaory refults on this fubjea. Not one of the patients who had fymptoms of catarrh, or inflammation of the lungs, fuffered the leaft inconvenience from the cold or tepid affufion ; none of their fymptoms were aggravated or increafed by it, but on the contrary moft of them were relieved. The tepid affufion was generally employed when the catarrhal fymptoms were ftrongly marked. The effeas of this application did not exaaiy correfpond with thofe ftated in your ioth chapter. In fome inftances it did not diminifh the heat of the fkin, or the frequency of the pulfe, even in cafes where the cold affufion produced thefe effeas. The tepid affufion was lefs permanent in its effeas, as you have obferved ; for in no cafe did it produce a total ceffation of the fever, al- though it always alleviated the fymptoms very much, and diminifhed their violence. The cold affufion generally arrefted the progrefs of the fever when it was employed early in the difeafe; but the cutting fhort of the fever did not always follow the reduaion of the pulfe and thq dimi- 39 3°o nution of the heat. In one cafe the heat of the body wag reduced 4^ deg. by the cold affufion applied in the evening; and in another, the pulfe was reduced thirty beats in the minute, without the difeafe being flopped. It appeared that the flow of the menfes was interruped by the tepid af- fufion, but they returned on difcontinuing its ufe, and no inconvenience followed."* • The cold affufion has been employed in fever with fuc- cefs in Glafgow, and feveral other parts of Scotland, but the details I have received relate to fingle cafes only, which it would be ufelefs to infert. From Dr. Bree, Phyfician to the General Hofpital, and to the Difpenfary of Birmingham, I have received a clear and valuable report, on the condition of the poor in that great manufaauring town, as far as refpeas health and difeafe. The limits to which I am confined prevent me from inferring it entire, but I hope it will in one form or other be prefented to the public; in the mean time I muft content myfelf with that part of it which more immedi- ately refers to the fubjea of this publication. Binningham, from the form of its buildings, feems lefs expofed to infeaious fever than Liverpool, or moft other great towns. The poor there do not inhabit cellars, and the courts are more fpacious and better ventilated than ours. Fever occurs there however as every where elfe, but it was more efpecially prevalent in the years 1799 and 1800. In the winter of *thbfe years, the remote caufes of fever exifted generally in" the dearnefs of provifions, and want of employment for workmen. Dr. Bree points out how thefe operate in a detail which appears equally juft and affeaing. The fever originating in defeaive nutrition and cloathing, depreffion of mind, and contaminated ^air, was * This account obligingly given me by Dr. Reeve, of Norwich, corref- ponds with communications made to me on the fame fubjeft, by my friend, and kinfman Dr. Thomas Duncan, and by Dr. Bouchel, of Ghent, both of whom attended the clinical ward, when conducted by Dr. Home thai winter. (1802-3). I hoped to have had a very full and precife communi- cation from Dr. Home himfelf, but an accidental circumftance has occafion- ed me to be difappointed. 3°7 often preceded by purging and vomiting, immediate effeas of debility in the firft palfages; when thefe were reftrained by medicine, fever very often enfued. " The fever" fays Dr. Bree, >our failors, who in the time that " they are delirious, or have calentures, when lying in their hammocks in a " calm Cummer's day, they fee the fea through the. gun pon>, very plain and " fmooth, and imagining it to bo a green meadow, get up a wjlk'ng, and " fail into the fea, but if they get at laft in>o their hammocks, (1. e. it they " are laken up alive) they fweat very plentifully, and make off their fever." Fee MeJicina Naut. v. iii. p. 27. 316 accounts which I have received from them are nor fuffi- ciently particular for publication. Mr. Wiifon, furgeon of his Majefty's fhip the Huffar, employed thecold affufion with extraordinary fuccefs in 1795. The Huffar had taken a French fhip from Guada- loupe off the Capes of Virginia, which had brought the yel- low fever out of port with her, of which m^ny had died. The difeafe fpread rapidly among the crpw of the Huffar, and the fhip running northwards, landed eighty-three perfons ill of the fever at Halifax, in Nova Scotia, in the month of June, There not being accommodation for them in the hof- pital, tents were fitted up for them on fhore, in which Mr. Wiifon attended them. His praaice was to bleed early, ge- nerally in an hour after the acceffion of the hot ftage.. He then gave a folution of emetic tartar. The cold affufion was always adminiftered in cafes of delirium, which it immediately removed, inducing tranquility and fleep. Of thefe eighty-three cafes, Mr. Wiifon did not lofe one.* I regret that we have not a more particular account of the praaice of Mr. Wiifon, In the burning fever of the Weft Indies, efpecially when it effeas youthful and vigo- rous Europeans, as in the cafe of the crew of the Huffar, it feems to me very probable, that early bleeding, follow- ed perhaps by antimonials, may fometimes be advanta- geoufly employed preparatory to the cold affufion ; and that the inordinate aaion of the vafcular fyftem being weakened by thefe previous fteps, the cold affufion may afterwards be more fpeedily effeaual. But this muft de- • pend on the vigour of the patient, and the effeas produced by thefe remedies on his temperature; which in no cafe ought to be reduced fo low as the ftandard of health, pre- vious to the cold affufion, and it feems alfo clear, that there is no fafety in the ufe of blood-letting or antimonials, ex- cept they are had reeourfe to in the very firft ftages of the difeafe, and in patients in the vigour of life, as in the prac- tice of Mr. Wiifon of the Huffar. There is little doubt that this gentleman was partly indebted for his extraordi- * Med/ Nautica, -vol. i. p. -$6\. V7 nary fuccefs, to his attending his patients in tents, where they muft have been much expofed to the open air, a cir- cumftance which at Halifax, in the middle of fummer, muft have been no lefs pleafant than falubrious. A praaice fimilar to that of Mr. Wiifon, was employed by Mr. Harris, Surgeon of the Thunderer. He alio bled in the firft ftage of fever, and gave clyfters of cold water, which were very advantageous.* Experience has taught me, that the heat of the fyftem may be effeaually reduced by clyfters of cold water, though not fo fpeedily as by af- fufion on the furface, or even by deglutition. Previoufly to the publication of the " Medical Reports," Dr. Trotter, Phyfician to the Channel Fleet, had recom- meded the cold lavation after the manner praaifed at that time by Dr. Gregory. His direaions were that every morn- ing, a towel dipped in cold water fhould be paffed over the furface of the patient, and afterwards that his linen fhould be changed.f After the publication of this work, he en- couraged the ufe of the cold affufion, as recommended in it, of the effeas of which he has given feveral ftriking and fatisfaaory accounts. Some of thefe I will take the liber- ty of extraaing. In June 1800, the cold affufion was employed by Mr. Farquhar, Surgeon of the Captain fhip of war. His ac- count of the effeas is as follows: " In feveral cafes of typhus which have occurred this month, I have made ufe of the affufion of cold water, and have found it fo anfwer my moft fanguine expeaations, particularly in two cafes where delirium had come on, and where, from the general debility, frequency, and irregu- larity of the pulfe, great heat of the fkin, &c. I had little hopes of recovery. The patients were put into a large tub, and had a couple of bucket-fulls of falt-water poured over them. The fhock which they at firft received, ap- peared to be very fevere, but the advantage which they derived from the praaice was fo great and manifeft even * Med. N^utica, vol. i. p. %6o. f Med. Namica, vol. i. p. 379. 3.8 to themfelvcs, that they willingly fubmitted to its repeti- tion next morning. They are both at prefent convalcf- cent."* In fpring 1800, the Ruffell man of war, commanded by Captain Sawyer, was dreadfully affeaed by contagious fever, which after being fubdued, broke out again in the harbour of Plymouth, in confequence as it was fuppofed, of frefh infeaion received probably from the imprefTtd men. The difeafe fpread with gieat rapidity, and great numbers were affeaed. In this epidemic, the cold affufion was employed by Mr. G. Magrath, the Surgeon, with the happieft effeas. Tn a letter to the phyfician of the fleet,f he fums up his experience of this remedy in the following words : " I have now had ample experience of the effeas of cold affu- sion in fevers, and from my own observation, will venture to pro- nounce it a safe and efficacious remedy, when the restrictions so judiciously laid down by Dr. Currie are attended to. I can affirm that no evil of any magnitude ever arose in the course of my praaice from its adoption, even when catarrhal symptoms were pre. sent. I have experienced, that the earlier this remedy is had recount to in the disease, in like proportion it will be found more effedual in arresting the progress of fever. " Several cases have yielded to the cold affusion, without the assistance of any medicine whatever; but I have found, that the prudent administration of evening anodynes, powerfully assists, In the more advanced stages, where the skin was dry and imper- vious, with more or less delirium, and where a cuticular discharge (sensible perspiration) could not be procured by the most power- ful sudorific medicines ; by throwing a bucket of cold water over the patient, rubbing him dry, and laying bim"between the blan- kets, I found a comfortable glow to succeed, followed by a gentle and salutary perspiration, first appearing about the forehead and neck; and by administering bland diluent drinks, such as balm, or sage tea, this perspiration would become general, the confusion of thought disappear, and the patient would fall into a calm and refreshing sleep, which sometimes lasted for hours. He would then awake much recruited, with an abatement of all the febrile symptoms; and in several a complete recovery took place under these circumstances. * Med. Nautica, vol. iii. p. 163. + Med. Nau'.ica, vol. Hi. p. *37- 3*9 " Indeed, invariable success has attended my endeavours ever since 1 began to adopt this pratlice on a large scale. It is now so perfeaiy familiar, that I have the utmost confidence in it; and feel justified in pursuing it from principles of humanity as well as of science. In some of the milder cases, I have known one bucket of water poured over the head and body produce such a shock, that the redundant heat and increased velocity of the circulation disap- peared, and never more returned. The disease was by this means cut short, which otherwise might have been protraaed to an un- certain duration with increasing malignity." The method of cure thus defcribed by Mr. Magrath, was purfued by him in the harbour of Plymouth, and drew on him the attention and obfervation of the Officers, as well as Surgeons of the fleer, but he did not fhrink from his courfe, and his triumph was in the end complete. Mr. Magrath was fupported by Captain Sawyer and his Offi- cers, whofe attention and charity towards the fick, kept pace with the able and benevolent arrangements of the Surgeon.* In confequence of a notice which I inferted in the Me- dical and Phyfical Journal, inviting particularly military and naval praaitioners, to favour me with the account of their experience of the praaice in fever which I had re- commended, I received an ample and valuable communi- cation from Mr. Magrath, dated, his Majeftys Ship Am- phion, Portfmouth, April the 29th, 1803, to the whole of which I would willingly give infertion here, if my limits would permit. Mr. Magrath has enlarged his experience of the cold affufion, fince the date of his communication to Dr. Trotter, and confirmed his inferences. " My first trial," says he, " of this remedy, was the conse- quence of multiplied disappointments in the ordinary modes of praaice, and it was resorted to with no little circumspeaion, on account of the inveterate prejudices of such a class of men as sailors are; but by steady perseverance, and dispassionate investi- gation, the happy effeas of the cold affusion were incontroverti- bly developed, to the conviaion of those on whom the remedy was used, and who were as anxious for its repetition at the proper periods, as I was to direa it. * Med. Nautica, vol. iii. p. 237- 32o " I have now put this remedy to the test of accurate trial, in upwards of a hundred cases of typhus, differently modified by climate and season, and diversity of constitution, sometimes complicated with catarrhal symptoms, and sometimes with affec- tions of the bowels, not only in the English Channel, but in the Baltic sea, and in the increased temperature of a southern lati- tude : and with invariable success. When employed in the first stage of fever, it frequently happens, that a single application is sufficient, and I have always observed, that it is more powerfully efficacious, in proportion as it is early resorted to, and that if ne- gleaed till the morbid catenation is strongly formed, the fever frequently resists the cold affusion for some time." Mr. Magrath laments, that the cold affufion has not been adopted generally in the navy, and expreffes his in- dignation againft perfons who have afperfed and reprobated it without trial, on mere prejudice. He anticipates the time as at no great diftance, when it will be firmly efta- blifhed. In this laft fentiment I perfeaiy agree; and in re- gard to the oppofition of ignorance and prejudice, we fhall bear it with more patience, when we recollea that it has fo uniformly prefented itfelf to all confiderable improvements in our profeffion, that we might begin to doubt of the great advantage of the praaice we are recommending if it wanted this genuine mark of utility and of importance^ In the courfe of his letter, Mr. Magrath adverts to the great number of fhips conneaed with the channel fleet, that in the courfe of the fpring and fummer of 1800, ff were contaminated with typhus contagion I" and confi- ders this contagion to have originated in guard (hips, tend- ers, and receiving fhips. The fame fentiment is delivered by Dr. Trotter, in his valuable record of the difeafes of the fleet—the Medicina Nautica, already fo often quoted. Dr. Trotter points out the Aaaeon, the receiving fhip at Liverpool, as in this refpea particularly obnoxious, and denounces the impreffed men fent round to Plymouth from her, as having fpread contagion through the channel fleet. I fear there is too much ground for Dr. Trotter's charge. In adverting to the Aaason, he has mentioned my having on one occafion been called to examine the condition of the men fent from this receiving fhip, and as the particu- 321 lars may ferve to illuftrate our general fubjea, I will give them here in detail. One of the veffels fent to convoy the impreffed men from the Aa^eon to the channel fleet, was the Reynard floop of war, commanded by Captain Spicer. She performed three voyages on this fervice in the courfe of the fpring and fum- mer of 1800. The firft cargo which he carried round, having been infixed with fever, and having, as it was fup- pofed, fpread it widely in the fleet, Captain Spicer was anxioufly defirous on his fecond voyage, to take no feamen from the Aa^eon that were not in perfea healthy. His or- ders, which he communicated to me, and thewcommander of the Aaason, were very exprefs to that purpoie. Accord- ingly, about an hundred men, fuppofed to be free of in- feaion, were fent on board of the Reynard ; but a contrary wind preventing Captain Spicer from failing immediately, he perceived, or thought he perceived, febrile fymptoms on fome of thofe men, two or three of whom he returned to the Aaason inftantly, and defpatched a fummons to me on fhore, to repair on board the Reynard and examine the reft.* I repaired on board accordingly, along with the gentlemen who fuperintended the department of the fick and hurt, and the impreffed men were paffed in review be- fore us. A flow contagious fever had got among them, and eighteen, who appeared to be affeaed, were fent to the hofpital on fhore. Captain Spicer failed with the reft, but all our care had not fecured him from the apprehended evil —four men were found ill of the fever on their paffage, and fent to the hofpital on the fhip's arrival at Plymouth. The Aa^eon deferved the charaaer given of her by Dr. Trotter ; (he was indeed a difgrace to the fervice in various points of view. After this time, however, greater regard was, I believe, paid on board of her to cleanlinefs and ventilation. The men fent on fhore were attended by Dr. Thomas Cochrane, formerly of the ifland of Nevis, and now refi- • I was unacquainted with Captain Spicer and no wife connected with the fervice; but no man could pauicipate moie fully in the anxieties of thisbrarr officer, or obey his call with greattr alacrity. 41 322 dent in or near Edinburgh, who had at that time the care of the French prifoners, and of the fick and hurt at this port. His praaice was to employ the cold affufion, and it was ufed in the cafe of thefe men with its wonted fuc- cefs. Thi» fever, which is faid to have fpread itfelf through the fleet, readily yielded to this Ample remedy. My friend, Dr. Carfon, now phyfician in Liverpool, affifted Dr. Cochrane, and on fome occafions aaed for him. He did not attend the individuals in queftion, but he has fa- voured me with the following particulars, which are im- portant in themfelves, and from which the fuccefsful praaice of Dr. Cochrane may be clearly inferred. " In the month of December, 1799, an epidemic fever ap- peared on board his Majesty's ship Aaaeon, stationed at this port to receive the newly raised men for the navy. My friend Dr. Cochrane, who at that time had the charge of the naval hospital on shore, was a great advocate for the use of the cold bath in fevers and spasmodic complaints. I had at all times permission to Visit the hospital. An occasion offered which I considered as favourable for using the cold bath, and I obtained Dr. Cochrane's permission to try the effeas of a remedy, to which he himself had, in such cases generally and successfully had recourse. " Five men had been sent on shore, who had been seized with the epidemic the preceding day. About nine o'clock at night, I found several of them in a state which, from attention to your rules, I considered proper for the application of the cold bath. They complained of great heat and thirst. Their skin was dry and hot, tongue parched, great restlessness, with occasional de- lirium ; pulse quick,, respiration anxious, though without any cough or local affeaion of the breast. I did not venture to apply the cold bath to them all this evening; but seleaed one whom I deemed the fittest subjea for it. This man, having been got out of bed, and placed in a large tub, two buckets full of cold water were poured over him. He was then put to bed; nothing further was done to him. In the morning I returned at an early hour, anxious about the success of the praaice, and had the satisfaction to find him free from fever, and to understand that he had passed a comfortable night. He had no relapse, and in a few days was returned to the Aaaeon in good health. The other four in whom the fever continued its course that night, without abatement, were next day, in the presence of Dr. Cochrane, treated in the same manner, and with exaaiy the same success. The remedy wai 3f ■"> most grateful to the feelings of all these men, and there would have been no difficulty in persuading them to use it a second time, had there been occasion for it. This was the general praaice with the fever cases from the Aaseon. " I have frequently seen the cold bath used in cases of fever, among the prisoners at war deposited here in the latter end of the late war, and always with complete success. But in the prison- hospital, fevers were, from obvious causes, too frequently attended with pulmonic affeaions to admit of the use of this admirable remedy." Dr. Carson has also communicated to me the following general testimony of the benefit of the cold affusion, in a letter to him from Mr. Simpson, Surgeon of his Majesty's ship Naiad: " Ship Naiad, at sea, June 22, 1803. " I have for a long time past been in habits of employing cold water externally, although in a different, and certainly far less extensive form than Dr. Currie recommends. And indeed, I do not know, who had any idea before his valuable communications, of the vast extent to which this scientific praaice may be carried. " In every case of typhus, that for a long time past came under my care, I have always assiduously put in execution the application of vinegar and cold water, by a sponge or towel, to the head, neck, and breast, regularly every morning and evening, and in cases where debility was not far advanced, I have perhaps used it oftener. And I can with truth aver, that I have succeeded in a great number of instances, in arresting fever at a very early stage by a timely use of the cold affusion, as recommended by Dr. Cur- rie. Indeed so successful have I been, that in all my reports for these last few years, I have scarcely had occasion to note any con- tinuance of fever for any remarkable time, although I am well convinced, that if I had not praaised the cold affusion, as recom- mended by him, I should not have been nearly so successful. " I have conversed with a number of ingenious men on this subjea, and they have unanimously concurred in giving the strongest testimony in favour of this excellent praaice. " I certainly feel authorised in saying, that fevers which from every rational consideration, that could be adduced from previous knowledge, were likely to prove tedious, if not extensively fatal, have by means of the cold affusion solely, as far as I could judge* been happily arrested, and terminated favourably. « In almost every stage of fever, I have found this remedy use- ful,, when prudently employed. When early put in praaice, that h 324 to say, as soon as the fever is properly formed, I never have found it fail of affording material relief; and generally a few ap. plications have aaually put an entire stop to the farther progress of the disease. " In a few instances however, when from the state of the pulse, skin, &c. I had apprehended, I should be warranted in using the aspersion with cold water from a jug, I found that this did not succeed so well as the simple ablution with a sponge. Very severe and long continued rigours followed the aspersion from a jug, and they did not terminate, as I had always found in other cases, in sleep, and a genial diaphoresis, nor was there the least abate- ment of head-ache. But this might proceed from the patients terror at the sudden and uhusual application. For certainly, un- til Dr. Currie's praaice became generally known, this application, the aspersing a person in fever with cold water, was quite repug- nant to the general received opinions, and praaice of mankind— at least I believe so," Thefe teftimonies in favour of the cold affufion, feem decifive of its beneficial effeas in the maritime praaice of our northern latitudes. If it were neceffary, it is in my power to add to them confiderably. Bur candid inquirers will be more defirous of knowing how far it is equally falu- tary in the deftruaive fever of the Weft Indies, by which our fleets and armies have been fo often enfeebled or fub- dued. In confequence of my addrefs in the Medical and Phy- fical Journal already mentioned, 1 received a communica- tion from Mr. L. F. Nagle, lately furgeon of his Majesty's fhip Ganges, which bears on this point; and which appear- ed to me fo very important in its nature, that I was defirous of giving it to the world with every ftamp of authenticity: and Mr. Nagle having referred me for his charaaer to Captain Freemantle, and Captain Baker, who commanded the Ganges, during the period of his fervice on board of her, I applied by letter to the firft of thefe gentlemen, the addrefs of the other not being known to me. The reply of Captain Freemantle, dated March 17th, 1803, was perfeaiy fatisfaaory. He fpoke of Mr. NasJe in the higheft terms; reprefented him as no lefs honeft than fkil- ful, and affured me, that I might place the moft perfca reliance on his reprefemations. 325 Satisfied with the high authority of Captain Freemantle, and with Mr. Nagle's own perfpicuous and unaffcaed narrative, 1 prefent it to the world with perfea confidence, and with fingular fatisfaaion. It was originally contained in a feries of letters, and reduced to one unbroken narra- tion at my requeft. Copy of a Letter from Mtr. Nagle to Dr. Currie. " His Majesty's Ship Royal Sovereign, " Portsmouth, May 9th, 1803. " Sir,—I took the first moment after my return from the West Indies, to acquaint you with the extraordinary success which has attended your new remedy in fever, the affusion of cold water, in my praaice on board his Majesty's Ship Ganges, of 74 guns, on the Jamaica station; and I very readily comply with your desire to give the particulars a little more in detail. " The Ganges was commissioned at Portsmouth in August, 1800, at which time I joined her as surgeon. She was then, and for some time afterwards remarkably healthy, from her high state of discipline ; but an infeaious fever was brought on board of her by some marines, from the Malta, at Spithead, in August, 1801.— Forty marines, and four seamen, ill of it, were sent on shore to the Royal Hospital, at Haslar, and this cleared the ship of the disease. We then sailed for the coast of France, and were on a cruise off Brest, from the 14th of September, to the 23d of Oaober, at which time we were ordered to Jamaica, where we arrived on the 2kh of November. During these ten weeks not a man died, and we reached the harbour of Port-Royal in remarkable health. We found a malignant fever prevailing among the shipping there. The mortality was particularly great on board the merchant ships at Kingston, many of them being almost unmanned by it. Soon after our arrival it broke out on board the Ganges, and spread rapidly, especially among the marines and landsmen, who had never before been in a warm climate. The symptoms were— severe head-ache ;—hot and dry skin ;—the face flushed ;—eyes red;—nausea ;—thirst;—the pulse strong, and full at first, and as frequent as 120 in the minute;—pains in the back and limbs;— great anxiety, and restlessness. The patients were in general un- der much depression cf spirits from the accounts we had received of the great mortality from the fever. There was little chilliness in any sta^e of the disease, and remissions were scarcely perceptible. Heat of the skin was the most striking symptom. To what degree it aauallv rose, I had no means of ascertaining, having unfor- 326 tunately, broken my thermometer. I was therefore obliged to trust to my sensations, and those of the patient. But from the impression on my hand, I have no doubt that the heat in this fever, was many degrees greater than the temperature of health, and considerably more than in the common fever of England. « The violent, and rapid nature of the disease, convinced me, that early and decisive measures were required, and I determined to have recourse to the affusion of cold water, under the direaions which you have given for its use. As soon therefore as the morbid heat fairly indicated the accession of fever, I poured a quantity of v sea water on the patient, from the head downwards ; generally two or three bucket-fulls; and commonly direaed the body to be afterwards wiped with a towel dipped in vinegar, but more with the view of preventing the sailors from thinking that I trusted entirely to the cold water, than from any supposition of the vinegar being required. I then put the patient into bed; gave him in general from eight to ten grains of calomel, with four or five grains of the pulvis antimonialis, and supplying him with plenty of di- luent drinks, left him to his repose. " The affusion, when used in the first, or even second day of fever, operated like a charm. The morbid heat and dryness of the skin were converted into an agreeable coolness, with some de- gree of moisture; the pulse sunk very often from 120 to 90; the head-ache, flushings, restlessness, and agitation disappeared; sen- sations of comfort were diffused over the whole body; and the patient fell into a natural and refreshing sleep. . On awakening, two or three passages downwards from the calomel, seemed to carry off every remaining irritation. Most commonly the fever did not return ; but if it did, the bathing was repeated once, or perhaps twice, as might be required. Where I had not an op- portunity of seeing the men for the first day or two of fever, which sometimes happened from their being taken ill on shore, and remaining there, the effeas of the affusion, though strikingly beneficial, were not so immediately decisive, and it was requisite to repeat it several times. I had seldom occasion to use opium in this fever, for the cold affusion produced sleep, and in three or four cases in which I gave opiates at bed-time, irritation and restlessness ensued ; the symptoms being increased which the cold affusion had obviated. We had one hundred and twenty cases of fever in all, during the time I served on board the Ganges on the Jamaica station, (that is, from November, 1801, to the end of July, 1802), in all of which the cold affusion was used, and of which we lost two only. One of these had been ill of a violent inflammation in the knee, for which I was obliged to 327 use bleeding largely, and in this reduced state he was attacked with the fever. The other was a marine, of a weakly habit, and a consumptive tendency. I did not use the affusion in this case, in the early stage of the fever, and when I did use it, I fear I per- sisted in it too long. These were indeed the only deaths which occurred on board the Ganges from the time we left Portsmouth, to the end of last July, a period of eleven months, as may be as- certained by my journal at the board of Sick and Hurt, and du- ring this time, two men only were sent to the hospital at Port Royal, one from an accident, the other from general debility * «The fever broke out first at Port Royal, as I have already mentioned, and we carried several cases to sea with us, on a cruise to the island of St. Domingo, on which we were out six or seven weeks; when we repaired to Port Royal to refit and refresh for a few days, and again returned to our cruising ground. In these successive cruises, our whole time was employed. We had a great deal of calms, with heavy rains, at intervals, off St. Domingo, and at this time the mortality was understood to be very great a- mong the French troops on shore. While at sea, we were often, for several weeks together, not only without fresh vegetables, but without fresh animal food, and without even a single glass of lime- juice, to correa the scorbutic tendency in the men. Many of my patients in fever had ulcers in their legs and feet, which had assumed a scorbutic appearance, from the want of those articles. In patients under these circumstances, the cold affusion was an incalculable blessing. It aaed like magic. It was generally used in the evening, and scarcely ever failed to produce a gentle per- spiration, and refreshing sleep, removing the symptoms of fever, and relieving the depression of spirits and anxiety of mind. A saline cathartic, such as I have already mentioned, completed the cure. By these means, we generally got clear of fever while at sea ; but it broke out again on our return to Port Royal, because there the men were often on shore, exposed to the heat of the sun, on watering and dock-yard duty ; and besides in harbour, discipline could not be so easily preserved, or drunkenness pre- vented. * " I had a gteat objection to fending oatients to the Hofpital at Fort Royal, from the air at fea being far preferable in the Weft indies for fever pat.ents. The mortality at the hofpital is orten very i,re.it, and many other dufcs prevent men from returning to their (hips again. Captain Fr.einantle was fo lenfible of this, that he would not allow a man to be fent on (hire, except in calcs of the moft urgent ne.efiiTy, knowing the great I .fs to me frrvice that good m:n are during the feafon or war. If proper diet is allowed by government, lheir recovery is more rapid at fe i, and taking care of them when ill on ihip-bo^rd, mjkes th.m more attached to the fervice. Dr. Trotter has very jultly r 'marktd the lofs the fervice fuftained, when the hofpital (hip was discon- tinued in the channel-flee'." 328 " 1 was soon so much convinced of the great advantage of using the cold affusion early, that I made a point of seeing immediately any man that complained; and I gave positive direaions to my mates, whenever I was out of the ship, to use the same vigilance, and to apply the affusion without delay. And I always kept one of the mates in the sick birth, during the night, to watch the ex- acerbations of heat, and where they appeared, to take the patient out of bed direaiy, and pour the salt water over him. " At first, my patients were startled with the proposal of this novel remedy; but after a little experience of its effeas, they sub- mitted to it cheerfully, and were even anxious to use it. As soon as the fever went off, J gave the bark infusion or decoaion, with a light nutritive diet, and in some cases, a little good wine and porter from the ward-room mess. " I leave you to judge what direful effeas the lancet must have had, employed on such patients as I have described. In those ships where veneseaion was used, the mortality was great. But the more general praaice, both in ship and on shore, was to trust chiefly to calomel, and to bring on salivation as speedily as possible. Of this medicine, as an auxiliary, I have the highest opinion. I generally used it as a cathartic, as I have already mentioned, and in some cases brought on salivation. But even in these instances, I never hesitated to use the cold affusion on the febrile heat recur- ring, and I never saw any injury from this praaice. " I never had recourse to blood-letting in this fever, although I •was incited to use it, both by precept and example. I am a deck ded enemy to this praaice in the fevers of the West Indies, and of other warm climates, both from reasoning and observation. It may perhaps be sometimes used with officers just arrived, of full habits, and who live freely. But it will not do with sailors, and especi- ally with those who are impaired by service, or by the climate.* " Neither did I encourage the use of emetics, which must ever, I think, be attended with dangerous consequences in this fever, * " I ferved in the Eaft Indies five years, (from 1793 to 1798), on board his ma- jefty's (hip Heroine, commanded by the honourable capt. Gardner, and the honourable capt. Murray, and did not ufe the lancet twelve times in that period of years, except in cafes of accident. " When the lancet wis ufed, it was chiefly in the incipient ftate of inflammation of the liver, in new comer?. Lord Hobart came home paflenger in the Heroine—'in our paffage from Madras to Spithead, we did not lofe a fingle man, and there was only one man fent to the hofpital on our arrival, in the laft ftage of a liver afteclion. I con- tracted a difeafe of the liver in the Eaft Indies, which appeared again in the Weft Indies, and obliged nr- to leave the Ganges, and come home a paflenger. Dr. Blane, late com- miflioner of fick and hurt, is no ftranger to my practice in the Eaft Indies ; nor is ihe ingenious Dr. Clark, of Newcaftle, who has made the -bert practical remarks on the difeafes of rhv climate ; remarks which may be depended on." 329 notwithstanding, that in one of the medical journals, a praaitioner of Jamaica mentions his giving a solution of the tartarum antimo- niale to stop vomiting ! In a case on board the Ganges, in which one of my mates gave this medicine, it brought on such violent retchings, cold sweats, and languid pulse, as alarmed me greatly. A large dose of tinaure of opium, in Madeira wine, stopped these symptoms. " The fever which prevailed on board the Ganges, was not confined to the sailors; it extended to the officers. Mr. George Allcot and Mr. William Carter had it. This last had three different attacks of the fever, and every time used the cold affusion. I have not the least doubt that he was saved by it, and that nothing else would have saved him. In the absence of the surgeon of the St. George, I was sent for on board that ship, to attend Mr. Yule. As usual, I prescribed the cold affusion, and with the usual happy effeas. Captain Lobb, who now commands the Isis, a man of superior talents in his profession, then commanded the St. George. He was much pleased with the praaice, and mentioned that he had known one surgeon of the navy before, who had adopted it, and with the greatest success. " If you ask whether this was the yellow fever of the West- Indies, I would answer that it was, though under the praaice I have described, the yellow tinge of the skin seldom appeared. " By whatever name it may go, it was no doubt the same fever that spread such destruaion through our naval and military ser- vice in the West Indies last war. I did not consider it as conta- gious. There was little chilliness perceptible in this fever—the remissions, if any, were very indistina. The patients complained of a burning heat, almost from the first. " While we lay at Port Royal, a merchantman came down from Kingston, and our purser, Mr. John Allcot, went on board of her to buy some coals. When he returned, he informed me that almost all her men were down in fever, and entreated me to go to their assistance. I found that she had already lost in this fever ten of her seamen and two mates ; four men were then dan- gerously ill of it. They were in a very dirty state; the symptoms were, a hot burning skin, flushed face, red suffusion of the eyes, rapid pulse, anxiety, restlessness, and delirium. I immediately put in praaice the cold affusion with them all, and with imme- diate and striking benefit; I direaed it to be repeated from time to time, as the heat might require it. I also sent each of them a dose of calomel and antimonial powder, to be taken next morn- ing. The master of the ship, who had been himself ill of this fever, and with difficulty recovered, was wonderfully struck with 42 33° this bold praaice, and with its obvious good effeas. The next day his steward being taken ill of the fever, he himself put him under the cold affusion, and sent to me for the medicine the others had taken. I visited the ship in the evening, and found the stew- ard quite cool and comfortable, and so far recovered from his alarm, which had been great, that he said he would attend his duty next day. All the others were doing well. " From the extraordinary success of my praaice, I considered it as a duty incumbent on me to publish an account of it, and I accordingly sent one to the Kingston Diary, of July the 25th, 1802, referring to your book, as the authority from which it was derived. Of this 1 have already sent you a copy. I hope, but ana not sure, that it was published, as I sailed immediately after send- ing it. I also made my success known to all my medical friends. I imagine the praaice is scarcely known at Kingston, as a medical man of considerable reputation there, wondered at my temerity, and was astonished at my success. The 2d battalion of the 6l)th regiment, stationed at Upper Park camp, lost a number of men from fever ; they were treated by mercury. On mentioning the success of my praaice with the cold affusion to the surgeon, he regretted the want of a liberal supply of water, to put it in prac- tice, the regiment being supplied by contraa from Rock port, some miles off. On my passage home in his Majesty's ship the Decade, the cold affusion was tried in all the fever cases that oc- curred, and with similar success to what I have already mentioned. " In a short time, it will I think, have as many advocates as the cow-pox." " I am, Sir, ".Your very obedient and faithful servant, (Signed) « L. F. NAGLE." It would be to no purpofe to comment on this moft im- portant narrative. fhe documents for the extraordinary exemption from mortality on board the Ganges, are the journals of Mr. Nagle, in the poffeffion of the board of fick and hurt. The means of this exemption are here detailed at large to the world. A comparifon of the difeafes arid deaths on board the Ganges, with thole of the other fhips on the lame flacion and fervice during the fame period, may be eafily made by the board, and the inference, it is pre'fumed, muft be irrifiitible. I fhall only add, the wa- ter employed for affufion on this occafion, being that of the fea, within the tropics, the temperature of which varies 33* from 75 deg. to 79 deg. it is probable, but not certain, that water of th s temper iture would be fufficiently cold for the fame purpofe in any latitude. But to produce the defired effea with wate. of this heat, more frequent affufions would in all likelihood be required. The only rule obferved by Mr. N.rgle in this refj>ea, was to repeafthe affufions when- ever the heat and reflleffnefs of the patient indicated theip ufe. I might here clofe the evidence in favour of this praaice in fevers on fhip-board, but the importance of the fubjea muft plead my apology for offering one other narrative which differs in fome particulars from thofe already given. The authorities hitherto given, have been countrymen of our own, engaged in fervice on the feas of the North of Europe, or of the Well Indies; the following ftatement, is from a foreigner exercifing his profeffion in the Mediter- ranean fea, or the contiguous parts of the Atlantic ocean. I muft preface it by a few remarks. In the beginning of laft March, I received a letter from Dr. Baeta of Lisbon, dated Feb. 2d, 1803, mentioning, that though a ftranger, he had thought it incumbent upon him to inform me of the fuccefs which had attended the praaice of cold affufion, during the fummers of 1801 and 1802, in fuch cafes of the fevers of that city, as it had been employed in ; the particulars of which correfpond precifely with the general reports on this fubjea. " In forty cafes- of fever,""fays Dr. Baeta, " which fell under my care, the general fymptoms were; pulfe from 110 to 130, and fome- times even to 140, in the minute; tongue dry and foul; thirft; fkin commonly dry; heat of the body generally above 100 deg. of Fahrenheit, fometimes 103 deg. and in three cafes 105 deg; high coloured urine; in fome cafes petechia, alfo coma, and delirium, with watchfulnefs and reftleffnefs." In the cafe of a patient, whofe fymptoms on the 4th day of fever, were; delirium; pulfe 130, and fmall; tongue dry; fkin dry ; heat 104 deg ; reftleffnefs and watchfulnefs ; the cold affufion was employed on the 13th July, 1802; one hour after, the pulfe was 10S, and a little more ftrong; 132 the heat 99 deg. with a gentle diaphorefis on the furface; the delirium had difappeared, and the patient felt light and comfortable. On the following day, continuing better, he took fome bark and wine, and recovered completely in five days." This may ferve as a fpecimen of Dr. Baeta's fuc- cefs. In communicating it to me, he mentioned that a friend of his had employed the fame remedy on a much larger fcale, in a fever on board the Portuguefe fleet, the particulars of which he offered to procure me. I accepted this obliging offer, in confequence of which, I received the following communication from Dr. Bernardino Antonio Gomez, phyfician of the Portuguefe fleet, which my limits oblige me in fome meafure to abridge : "Lisbon, 15th June, 1803. " Sir,—As my friend Dr. Baeta informed you, that I had made use of the water of the sea, in the treatment of infeaious fever; and as you expressed a desire to know the result, I present you with an account of it, to which indeed you are entitled, since it was from you, through the medium of your estimable work, the Medical Reports on the Effects of Water, that I learnt the use and efficacy of that remedy ; a remedy, which, when the dread which its novelty and singularity excite shall subside, will become as ge- neral in praaice, as salutary in its effeas, and which will render the names of Wright and Currie celebrated and revered; the first as its discoverer; the last as having regulated its application, ex- tended its use, and rendered its utility incontrovertible.* " In the beginning of January, 1802, a Portuguese squadron sailed from Lisbon, consisting of three frigates and three brigs, to cruise in the Straits of Gibraltar, and check the incursions of the Algerines into the Atlantic. Two months afterwards it was joined by a ship of the line. " From the time of its arrival in the Straits, a fever began to spread throughout the whole squadron, and prevailed to such a degree, that about the middle of March, one of the frigates and a brig returned to Lisbon, with two hundred ill of it on board; and in the beginning of June, when I was sent to the squadron, the sick amounted to two hundred and twenty, not including * I feel fome difficulty in publishing this high encomium,.I may plead, that it being fliared with Dr. Wright, I had fcarcely a light to fupprefs it; and that it may ferve to convey fome notion of the impreffion made by the practice in queftion, on this accom- plished foreigner, to whom Dr. Wright and myfelf are, pcrfonally, equally unkncwn. 333 those in the Swan frigate, taken through scandalous negligence by the Algerines, in which alone there were forty ill in bed." Dr. Gomez obferves, " that from the univerfality of this fever on board the Portuguefe fleet, in fome of the fhip* fcarcely an individual efcaping while feveral Englifh and American fhips of war at Gibraltar, remained in perfect health, there is no doubt that it was contagious, and though he declines tracing the contagion to its fource, there is little queftion that it originated in the want of cleanlinefs and ventilation, which, without experience, as well as the ftria- eft difcipline, are fo difficultly preferved on board crouded fhips of war. The fever came on as ufual with laffitude and cold ri- gours, fucceeded by fevere head-ache, wandering pains over the body, and great heat. Ihe tunica adnata of the eyes was often fuffufed : in fome there was flight ophthal- mia, and in others tranfient fymptoms of cynanche. In feveral inftances there were pulmonary affeaions, conftitu- ting what may be called peripneumonia notha; thefe fymp- toms of the inflammatory kind did not.continue through the difeafe. There were the other ufual fymptoms of fever; thirft; naufea; occafional vomiting; white tongue; fre- quent pulfe; the fkin dry, and hot to the touch, but in the few cafes in which the heat was meafured by Dollond's thermometer, it did not exceed 103 deg. of Fahrenheit. Haemorrhage from the noftrils often occurred in the early ftages, and when moderate, feemed falutary, by relieving the head-ache; but when profufe was dangerous. The blood drawn in a few cafes from the arm, did not exhibit the inflammatory charaaer. If the fever did not terminate in from four to feven days by a critical fweat, the tongue became dry, black, and tre- mulous; the pulfe feeble, and at times irregular; watch- fulnefs, delirium, and fubfultus tendinum came on, with all the ufual fymptoms of the worft form of typhus. Gangrenous fores appeared on the nates; fuellings in the parotid glands, in fome during, in others after the fever; and in two inftances there appeared buboes in the groin. In fhort in malignity, this fever feems to have approximated the plague. The favourable termination was either early 334 and fudden by a profufe perfpiration, or flow and without apparent crifis. The haemorrhages, tumours, &c. were never critical. Dr. Gomez on a review of the fymptoms, which he makes at fome length, decides, that this was the typhus gravior, or febris fenfitiva inirritata of Dr. Darwin. Du- ring the prevalence of thefe dangerous cafes there were milder forms of the difeafe, in this, as in other refpeas, the epidemic bearing much refemblance to the plague in the French Egyptian army, as described by Dr. Pugnet.* " Although," fays Dr. Gomez, " the work of yours which I have already quoted, had convinced me of the utility of the cold affufion in typhus, I did not venture to make ufe of it immediately on my joining the fquadron, for the ftrangenefs of the remedy made me more timid tharr I ufually am with regard to new remedies, though of an aaive kind. " I refolved firft; to become well acquainted with the fever, and to prepare by degrees the minds of my inexpe- rienced affiftants and others, to fee without murmuring, a praaice fo fingular and unheard of. I began therefore, by the ufe of water mixed with vinegar, limply as an ablution; I attefted the ftill greater efficacy of the afFufion of fea-wa- ter; and pointed out in particular the relief which a patient had received in a dangerous ftate of fever by merely remo- ving to a cooler place. " Having by thefe means made a favourable impreffion on the bye-ftanders, I waited only for a proper opportunicy to put the affufion in praaice. The cafe of a patient whofe pulfe was 156, his heat 103 deg. his fkin dry, and mouth parched, feemed to afford this opportunity, and I direaed three gallons of fea water to be thrown' over him. After drying him and putting him to bed, I found his heat and other fymptoms of fever abated, and foon after he went to fleep; but he awoke in a fhort time, as hot as ever. I therefore ordered him to be put into a tub and wafhed with fea water till his fkin felt cool, but not long enough to give * Memoire fur les Fievr. pefiil. & in/id. du Levant, p. 125, 214, 215. 335 him a painful fenfation of cold, or to make him fhiver; after this ablution his pulfe fell to 136, and the heat of his furface became natural. " The next day neither the heat nor the pulfe rofe fo high as before, and as he then complained of pains in his bowels, and of loofenefs, which laft he had had from the firft, though it had not been mentioned to me, I did not repeat the affufion or ablution. His feverifh fymptoms diminifhed, but the pains in the bowels and the ftools in- creafed, and the evacautions at length became bloody, fb that it appeared as if a typhus was transferred into a dyfen- tery. The patient was cured, though he fuffered a good deal from the affeaion of the bowels. In confequence of this cafe, there might perhaps be added to your contra- indications to the ufe of cold water in fever, a tendency to dyfentery.* " Although the refult of my firft trial was not the moft fortunate, it proved the power of cold fea water applied ex- ternally in diminifhing the pulfation of the arteries, the burning heat, and drynefs of the mouth; and in procuring fleep; advantages which encouraged me to the free ufe of the remedy on all proper occafions. " This I praaifed thence-forwards, with fuch extraor- dinary fuccefs, as produces a fenfation in my mind, of re- gret for not having ufed it fooner, joined with a fingular fatisfaaion in the confcioufnefs of having been the inftru- ment of bringing into ufe on board our fhips of war, a re- medy always at hand, and which poffefling almoft miracu- lous virtue againft the moft frequent and terrible of difeafes that affca navigators, may perhaps be denominated the greateft d.fcovery that has been made in the general prac- tice of medicine." Dr. Gomez adds, that it would be un- neceffary and tirefome to detail the vaft number of cafes in which he made ufe of the external application of fea water ' The reader will fee, that fome of my correfpondents have ufed the cold .iffufion with fuccefs, in cafes where diarrhcea or dyfentery were prefent; but mv own experience rather ferves to confirm the obfervations of Dr.. Gomez. D.. Lind, however, fpeaks cf the cold affufion as a cure for the chronic dy- I'sntery of warm climates. Effay on the Health of Seamen, p. 49. J. C 336 —The refult was, that he fpeedily fubdued this dreadful fever, and reftored the health of the fleet. In the application of the remedy, Dr. Gomez employed a method fomewhat peculiar. " I have mentioned already," he obferves, " that in the firft trial I made, 1 conformed to the method of Dr. Wright, which you, Sir, have re- commended and adopted—the method of affufion; but I alfo added, that I foon after employed in the fame cafe, ablution alfo; and this laft method I afterwards employed in moft of the cafes that occurred. My praaice was to place a tub at the foot of the patient's bed, with a little ftool in the middle of ir, on which he fat down naked. It was filled about nine or ten inches deep with fea water; one or two afiiftants dipped fponges in the water, and wafhed the patient all over, continuing this praaice till the furface be- came cool to the touch, and the fkin began to corrugate, but ftopping before the patient began to fhiver or horror cameon." Dr. Gomez gives his reafons for ufing this method/ which are fhortly thefe. That he found by experience the cooling effeas of a fingle affufion fpeedily went off, and that though by repeating the affufion, fufficient refrigera- tion might in the end be produced, yet that this was not effeaed without trouble, which the other method faved \ while at the fame time it was more agreeable, and equally fafe and effeaual. " In your country," he obferves, " the temperature of fea water being from 44 deg. to 60 deg. it may in the rapid method of affufion carry off the excels of heat and even more; but in a place, and at a time, when the heat of the air was from 75 deg. to 79 deg. and that of the fea water in a bucket, from 69 deg. to 72 deg, the effeas of a fingle affufion fpeedily went off; ftill I allow that the affu- fion when fufficient cold is produced by it, is a method more aaive and decifive, and on that account preferable in the beginning of fevers, and where the patients are vigo- rous. But when the progrefs of the fever has debilitated the patients, and the temperature of the water is much ^bove 60 deg. I think ablution preferable, being more 337 mild and fafe, and equally efficacious." Dr. Gomez con- fiders the aaion of the remedy, as producing two different effeas, the fubtraaion of the morbid heat, and the inrer- ruprion of the febrile affociated aaions. The firft he juftly confiders as moft important, as indeed abfolutely effential to the other, fince with the return of the morbid heat the febrile aaions muft return. The indications of Dr. Gomez, for the ufe of the ablu- tion or affufion, are the fame as thofe fo often laid down in this volume—morbid heat and drynefs of the fkin, without topical inflammation or dyfentery. " Under thefe condi- tions," fays he, " I boldly and happily ufed this remedy at any period of the fever. Occafionally.I examined the heat of the patients by Dollond's thermometer, and found it from ioo deg. to 103 deg. but as thefe examinations ex- pofed me to contagion, through the want of a thermometer properly adapted to the purpofe, as they required time, and the number of my patients was very great, I gave up experiments by the thermometer, and trufted to afcertain- ing the heat by the touch, a method fufficiently exaa for direaing praaice. " The refult of this praaice, except in the firft trial which I have detailed at length, and in which fome incon- venience occured, was uniformly advantageous. By its means I obtained, " 1 ft, A reduaion of the heat of the fkin to its natural temperature. " 2dly, A grateful fenfation all over the frame. " 3dly, A diminution in the frequency of the pulfe, of from 8 to 20 pulfations in the minute. " 4thly, A diminution of the drynefs of the mouth, bad tafte, and naufca. " 5thly, Calm and refrefhing fleep. " 6thly, A falutary fweat which terminated the fever. " This fweat appeared in fome cafes immediately after the patient's removal from the bathing tub inro bed; ia 43 33« fome it took place during the night; in others the day fol- lowing. " In thofe cafes where the fever did not terminate in 24 hours after the bath, the lucceeding acceffions were always lefs violent, fc that if it was not entirely gone after the fe- cond or third bathing, it was fo much reduced that I left off the bath, and completed the cure by the cinchona." Dr. Gum z alfo notices as a very general 'effea of the cold bat 1, tne reftoration ol the tone of the ftomach. To illuftace thefe general pofitions, Dr. Gomez details fix cafes much at large; they are very fatisfadtory, but fo nearly refemole other cafes contained in profufion in this volume, that it is unneceffary to infert them. He infers from thefe cafes, and from his general praaice, the inuti- lity and occafional difadvantagcof emetics, which in fome inftances were followed by a burning heat not before expe- rienced. He allows however, that they may be ufeful in cafes where the ftomach is loaded with bile, but he depre- cates their being given in the advanced ftages of fever, merrly on the ground of naufea being prefent, a fymptom which he confiders as arifing from debility, and which in this epidemic was very generally removed by the cold ablu- tions. Neither L he an advocate for blifters. The com- bination of catarrhal affeaions, with the contagious fever, did not prevent the ufe of the cold ablutions or impair their beneficial effeas. Dr. Gomez gave to his patients a nourifhing bland diet; and for drink, mucilaginous liquids, and lemonade, with fometimes an eighth part, and in other cafes a fourth part of wine. The quantity of wine ufed on the whole feems to have been very fmall, and he gave opium only in par- ticular cafes. On the whole, his praaice appears to have been in every refpea no lefs judicious than fuccefsful. Dr. Gomez is of opinion, that the cold afffion or ablu- tion may be extended to the exanthemata, and gives in proof of this a cafe of eryfipelas, affeaing the face and head, in which it was evidently advantageous. He notices and approves my recommendation of this remedy, in the 339 eruptive fever of fmall-pox, and of Scarlatina, and offers fome ftrong arguments for making a trial of it in the plague, quoting on this occafion, the cafes from Defge- nettes, which I have introduced, in vol. ii. p. 259 &f 260. He concludes his detail of the laft of his cafes of fever in thefe words; " it is remarkable, that when this patient was difcharged, the contagious fever was extina in the fquadron, nor was there in the hofpital any other patient under fever." The narrative of Dr. Gomez, fhews that where the mor- bid heat in fever is not fubdued by a fingle affufion, a more permanent application of the remedy may be reforted to in the form of continued ablution, thus confirming the recom- mendation given in vol. i. p. 181, to perfons engaged in pradice in the torrid zone. Continued ablution or immer- fion may doubtlefs be employed where neceffary, with fafety, due regard being always had to the aaual effects on the pa- tient's tempeiM'-ure. Ir is true, in the praaice of Mr. N.igle in the Weft Indies, which we have juft given, af- fufion feems to have been as effeaual as^uld be defired in fubduing morbid heat, though the wmer of the fea within the tropics is warmer than in the Mediterranean j but fome difference will probably be found in this refpea, not merely in different cafes of fever, but in different epi- demics, when the ftate of the animal heat, the moft im- portant of all the fymptoms, fhall be regularly introduced into the hiftory of febrile difeafes. Here then we clofe this divifion of the fubjea. It muft ferve to recommend the cold affufion in fever on board of our fleet, that it is not only the beft remedy for the fick, but the beft means of preventing the progrefs of infeaion ; with this farther advantage, that it is of all others the moft eafily applied. If it be compared with the remedies re- commended by Dr. L.ind, Dr. Blane, and others, its real value will be fairly appreciated.—The fcience of medicine, hitherto on occafions fuch as thefe, comparatively feeble and unavailing, by the adoption of this praaice, affumes a higher charaaer, and the fanative powers of nature more than cope in-force and rapidity with its deftroying powers. HQ CHAP. V. Some Account of the Ufe of the Cold Affufion on Shore, in the IVarmer Climates. HAVING in the preceding chapter, ftated fuch infor- mation as has reached me, refpeaing the ufe of the co! i affufion in febrile difeafes at fea, I fhould now give fome particulars of its effeas in the fevers which have attend- ed our armies on foreign fervice. My information under this head is however very defeaive, a c.rcumftance 1 particu- larly regret. I have not been favoured with much private information from our mditary practitioners, and I have to lament, in common with all who are competent to judge on the fubjea, that the medical hiftory of our military ex- peditions is njgk regularly given to the world. This is a duty which might be impofed on the chiefs of the medical ftaff with propriety and advantage. It would operate as a pledge for their attention ; it would bring their knowledge and talents to the tribunal of the public, and particularly of their own profeffion ; and it would be a means of pre- venting ignorance and prefumption from intruding, or be- ing intruded into fituations, where their effeas muft be Angularly melancholy and difaftrous. It has already been mentioned, (fee vol. i. p. 183), that on the northern fhores of the Mediterranean, where the ufe of the cold bath in fevers was frequent among the ancients; and the ufe of cold water as a drink, the prevailing prac- tice, thefe remedies have fallen into difufe in modern times; in part probably from the influence of a falfe theo- ry, and in part from the fudden and fatal effeas which muft occafionally have occurred, from the exhibition of fuch powerful remedies, while the principles which ought to regulate their application were unknown. The falutary praaice of antiquity, has "been revived in that region un- 34i der happier aufpices, by Dr. Dewar, now phyfician in Manchefter, (1805), affiftant furgeon of the fecond or Queen's regiment of foot, as appears by his letter in the 59th number of The Medical and Phyfical Journal, of which the following is an extraa. « The Second, or Queen's Regiment of Foot, forming part of Sir Ralph Abercrombie's army, arrived from England at Minor- ca, on the 21st July, 1800. Being sent to attend a detachment of it on board the Thisbe frigate, and afterwards doing duty with the whole regiment on shore, I had occasion to observe the faas I am now to describe. " The men enjoyed good health while on board, with the ex- ception of two or three-cases of intermittent fever, which had broke out on the passage, and a cholera morbus, which appeared in the harbour in an alarming form, though with no fatal conse- quences. But on the 11th of August, two days after they were landed at Mahon, an ardent fever appeared among them, which in a little time made considerable progress. " For a whole week, sixteen men, on an average, were taken ill each day. Their complaints, for the most part, came on sud- denly, and very often when they were on parade. After slight languor and debility, the patient was all at once seized with vio- lent head-ache, giddiness, pains, and extreme debility, in the low- er extremities, rendering him totally unable either to stand or walk. When he was brought to the hospital, we found him la- bouring under all the symptoms of the most violent pyrexia, in- creased heat, quick pulse, and urgent thirst. Two or three of them had very frequently alternations of heat and cold; but, in all the rest, the preternatural heat of the skin was constant, and the patient's feelings uniformly hot and oppressive. The symptom of which they all most violently complained, was the .excruciating head-ache. " I shall not trouble you with the observations I made respea- ing the causes of this fever, or the different remedies I employed, but confine myself to an account of the cold affusion. My opi- nion of its efficacy was previously fixed, from the perusal of Dr. Currie's valuable Reports, and from some striking cases which I had seen in the Edinburgh Infirmary, under the care of Dr. Gre- gory. I had the happiness to find that Mr. Wells, then surgeon to the regiment, entertained a favourable opinion of this praaice, and that we had an opportunity of accommodating a great pro- portion of the patients in a regimental hospital under our own care I presaged the happiest consequences from it among the 342 men; and seized with avidity the opportunity offered, not of con- firming my own belief in its advantages, but of observing such faas as might further elucidate the subjea, and afford additional evidence to convince my medical friends of the high utility of this praaice. " In the mode of application, I observed the rules laid down by Dr. Currie, together with such precautions as appeared a priori to be diaated by reason. The patients to whom it was applied, were those whose skin was uniformly hotter than natural, and parched. I never used it where there was much perspiration; but, on the authority of Dr. Currie, I considered a slight mois- ture of the skin as forming no objeaion to its use. While the patient laboured in this state under tormenting head-ache, and every symptom of violent fever, I took, him out of bed, stripped him quite naked,* and desiring him to hold back his head, and shut his eyes and mouth, poured a quantity of pump water first over the head, then over the breast and back, then washed the arms and palms of the hands, the thighs, legs, and soles of the feet; when the extremities, formerly hot, now became cooler. The heat generally returned about the region of the heart; while, in the head, it continued during the first affusion with little abatement. I therefore again washed the head and breast, and so on alternately, till the whole surface became much cooler than before. After this the patient was laid in bed. If in the course of eight or ten minutes, the heat returned with equal or nearly equal intensity, he was taken out, and the operation repeat- ed. The head-ache being the most obstinate symptom, and the last to yield to the cold affusion, the head was ordered to be sha- ved, and kept constantly cool, with a fold of linen laid lightly on, and dipped in water or brandy. Next day, whatever comparative relief the patient might experience, if any considerable febrile heat remained, the operation was repeated. In this application, I conceive it to be of great importance to begin with the head. The head-ache is attended with an external heat much greater in the head than over the rest of the body, indicating a peculiar force of increased aaion in that part of the system. To begin therefore with cooling the head, tends to restore uniformity of aaion through the system. The same circumstance renders it nectssary to keep the head cool during the whole course of the disease. "The effea of the cold affusion thus applied, was an immediate relief from the head-ache, from the heat of the skin, and all the * " When I hadoccafion to apply it to females, their deliocy was faved by allowing them to rcjin their ihift, which was changed immediately after the operatio:.." 343 symptoms of pyrexia. In every case the rapidity of the pulse was diminished, and the patient always felt immediate comfort. In many cases, after ten minutes, a gentle perspiration broke out over the body, which still further pro.noted the cure. Next day, if the febrile symptoms returned, they were always milder, and a second application of the remedy greatly diminished them. The head-ache continued for. some time after the other symptoms went off, but by the perpetual use of cooling applications it gradually de- clined, (seldom requiring the application of a blister), and left the patient with no vestige of fever, except a degree of debility. In most cases a yellow suffusion appeared over the surface in the latter stages of the disease, but it gradually went off,- and seemed to re- quire no peculiarity of treatment. As medical men, in adopting a new remedy, are often too zealous for its indiscriminate use, and those authors who treat on the subjea might be suspeaed of overlooking some of the occasional bad consequences of their praaice, I made it my business to attend to the varieties of the phenomena, and to observe whether or not in any case, this ap- pellation was ineffeaual or seemed hazardous; but I could find no instance of this kind. Those patients who had previously a slight moisture on the skin were benefitted as well as those whose skin was parched. Some shuddered and started when the water was applied, but this unpleasant sensation was very momentary, though I confess, in observing this, I would use the precaution of applying the water rather more gradually, lest an excessive shock should overpower the system in this state of febrile sensibility. The only patient in the regiment to whom the fever proved fatal, was an officer, whose obstinate disposition resisted the application of every powerful remedy, and in whom indeed the disease assu- med a different type, from his being subjea to a constitutional gloominess of mind, increased at that time by misfortune. I at- tribute the general efficacy of the cold affusion, on this occasion, in a great measure to its early application. " A similar fever was very prevalent among the natives of this island, but still more so among the British troops, where it broke out in each regiment at a different time. From any information I could collea, the cold affusion seemed to be unknown to the physicians of the island, nor could I even find any instance in which it was employed in our military hospitals. Some of my friends advised me against its use, from the unpleasant specula- tions to which its novelty might give rise. One gentleman, whom I in vain endeavoured to prevail on to employ it, told me after- wards, that he had, notwithstanding, kept the heads of his pa- tients cool in the same manner as I had done, and found it inva- riably serviceable for alleviating the head-ache. In many patients 344 in the island the fever was attended with high delirium on the second or third day. None on whom the cold affusion was used had any delirium worthy of notice. Some of them complained of giddiness in the erea posture, and their minds were observed to waver a little during the night. From this I concluded that a strong tendency to delirium had existed, but was checked by the same remedy which removed the other symptoms. In many the fever was evidently cut short at once, and in all of them I had reason to think that its course was rendered much milder. The emaciation which appeared among the convalescents was not to be compared to that which generally takes place in fevers so vio- lent. The disease, under this treatment, proved much less for- midable than in the ships in the harbour, and in other regiments on shore, where its fatality in some instances spread no small con- sternation. " Knowing the present spirit of enterprise which prevails in the medical world, I expeaed on my return to this country in 1802, that the cold affusion must be universally employed, and was ra- ther mortified to find, that though no faas were brought forward to its discredit, many medical men seemed very unwilling to employ it. It is rather singular, that while new articles, formerly reputed poisonous, are daily introduced into the Materia Medica, and ex- periments are made with them not only without scruple, but with zeal, the affusion of cold water in fever, a pradfice frequent among the ancients, and employed with advantage by some rude nations of modern times, should be considered as too extraordinary in its nature to receive a trial." Edinburgh, Nov. 14, 1803. It is to be regretted, that the praaice of Mr. Dewar was not generally known and imitated in the army of Sir Ralph Abercrombie, a body of men fingularly precious to their country. The ufe of cold water as a drink in fevers, we know to have been long the praaice of the native Egyptians,* and if we may give credit to Savary, the external, as well as the internal ufe of this remedy is common am^ng them, even in our own days. He obferves, in his Letters on Egypt, p. 242, " that if heat were the fource of the dif- " orders of that country, the Said would be uninhabitable. cc The burning fever (the caufus of the Greeks) is the only * See Alpir.us, lib. ii. cap. 15. 345 " one it feems to give rife to, and to which the inhabitants " are fubjea. They foon get rid of it by regimen, drink- " ing a great deal of water, and bathing in the river " In page 225 of the fame work, he gives the cafe of a mafter of a fhip, a man of credit; as related by himfelf, who having taken fome failofs on board affected by the plague, at Conftantinople, caught the infcaion. " I felt," fays the mafter of the fhip, " an exceffive heat, which mad« " my blood boil, my head was foon attacked, and I per- " ceived that I had but a few moments to live. 1 employed " the little judgment I had left to make an experiment. I " ftripped myfelf quite naked, and laid myfelf for the re- " mainder of the night on the deck : the copious dew that " fell, pierced me to the very bones ; in a few hours it ren- " dered my refpiration more free, and my head compofed. " The agitation of my blood was calmed, and after bathing " myfelf in fea water, I recovered," In a former part of this work, (vol. ii. p. 260.) I have fuppofed, that the ufe of cold water externally, which was unknown to the French army in Egypt, was equally un- known or negleaed in our own army there. By a com- munication from James M'Gregor, Efq. fuperintendant- furgeon to that part of our army, which landed in Egypt from India, in 1801, I find my fuppofition was not per- feaiy correa, " In the peft-houfes of the Indian army," fays he, " we were at firft very unfuccefsful, and a trial was given to a variety of modes of praaice. I find on an examination of the reports, that bathing with a folution of nitric acid, and fponging the furface with vinegar, and water, and lemon- juice and water, were attended with the beft effeas." The hiftory that follows fupports the narrative of Sava- ry, and very exaaiy refembles that quoted in p. 259 and 260, from M. Defgenettes. "About the middle of Oaober, 1801, a Hindoo, attached to the commissary m cattle, being seized by the plague, was by his surgeon conduaed to the pest-house of Rosetta, but on the even- ing of the same day made his escape, and though fired at by the centinel, got clear off. We heard no more of him for nearly 44 346 four weeks, when he was found concealed among the reeds o& the banks of the Nile, near Boulac, from whence he was sent down to the army then encamped near Rosetta. On his arrival I inspected him along with his surgeon, Mr. Guild; he was free from bubo and other symptom of fever or plague. He must have lived chiefly on sugaVcane, rice, dates, and what he could steal; and being fearful of hjrling incurred military punishment by running away from the pest-house, he had concealed himself carefully among the reeds on the banks of the river." It appears from what Mr. M'Gregor remarks, that the Hindoo eould not have made his escape, had he not been in the first stage of the disease, before his strength was broken, for he observes, " that in severe cases of plague, and in the advanced stages, pa- tients were not only incapable of moving themselves, but bore motion of any kind very badly, worse indeed than in any other febrile disease I have witnessed." He adds, « did mental vigour, arising from a determined resolution in the Hindoo to escape from a hospital, from whence hitherto not one of his countrymen had return- ed alive, support him in his flight ? However this may be, from what I myself have seen, I have no doubt that his exposure to the open air by day and night, and perhaps his diet and situation in other respeas, conduced to his recovery." " I find that I was correa in stating to you, that on the continent, in 1794, and 1795, I often saw cases of typhus do well in the wag- gons, with whom my mode of treatment had failed in our hospi- tals. The waggons were commonly farmers' waggons and carts, which were of course open at the top, and the patients therefore exposed to the weather. It frequently became my duty to press these waggons, not only for the 88th regiment, but for the sick of the brigade. " From my journals while in the West Indies, I could adduce a number of cases where the cold ablution had the very best effe&s in the yellow fever, and also in the typhus, when it prevailed much in the island of Jersey, in 1794, and 1798, but the prac- tice is now so generally known, that to multiply instances of its success is unnecessary. " One other faa appears on my journal while in Egypt, which now strikes me as remarkable, and may not be unworthy of your notice ; it ought perhaps to be generally known. " After crossing the great desart in July, 1£01, from a diffi- culty in procuring carriage, no ardent spirit was issued to the troops in Upper Egypt. At his time there was much duty of fa- t'gue, which for want of followers was done by the soldiers them- 347 selves; the other duties were severe upon them; they were fre- quently exercised, and much in the sun ; the heat was excessive; in the soldiers' tents in the middle of the day, the mercury in the thermometer of Fahrenheit, stood at from 114 deg. to 118 deg. but at no time was the Indian army so healthy."* While we are fpeaking of the countries contiguous to the Mediterranean, it may not be uninterefting to refer to the praaice, in fever, in the regions that run fouthwards, and particularly in Perfia during the 17th century, as defcribed by Sir John Chardin.f The Perfian phyficians, he informs us, were then, as they are probably ftill, religioufly difciples of Galen, whom they fuppofed to have been contemporary with Jefus Chrift, and to have had much intercourfe with him. For the dy- fentery, their moft common remedy was four milk, mixed with rice previoufly boiled in water till it had become quite dry. Bathing was one of their great remedies, efpe- cially in fever, as appears from his own remarkable cafe, which has often been referred to erroneoufly, and of which the following is an abridgment. On the 20th of May, 1674, Chardin had reached Ben- der-Abaffi on the Perfian Gulph, oppofite to the Ifle of Ormus, in the 27th degree of north latitude, where he waited for the arrival of a fhip from Surat which was to carry him to India. The place at this feafon, was very unhealthy, and being'himfelf and moft of his people af- feaed by it, he was advifed by the phyficians not to re- main, but to return through Perfia by land. He fct out on his return accordingly, and on the 23d was feized with a violent attack of fever with delirium, followed by ftupor, from which he recovered with difficulty. He had a French furgeon with him who gave him every affiftance in his * Thefe obfervations are important, and Mr. M'Gregor's authority is of great weight. His field of exoerienee has been uncommonly extenfive, and from the time he entered into the army, in 1789, he has kept regular journals of his practice. He ha» ferved in all the quarters of the world, particularly in the Eift and Weft indies, in Egypt, in the campaigns of 1794 and 1795, on tne continent, in the iftands of Guernfey and Jerfey, and in Great Britain. f Sir John Chardin was a French Proteftant refugee, by trade a jeweller, in which character he made a number of journeys into Afia. He was knighted by Charles 11, His works were published in 10 vols. i2mo. at Amfterdam, in 1688, in French, and it ijt from, this edition I ouote. No trareller ftands high-r i'cr accuracy and fidelifv. 348 power. The air of the country where he was taken ill, was fo bad, that he refolved to be carried forwards in fpitc of his weaknefs; and for this pirrpofe eight men were hired, who made a fort of litter or bier, of canes and branches of trees, on which they undertook to carry him on their fhoul- ders to the village of Laar. For the two firft days of this mode of travelling, the fever continued, with frequent faintrngsj but on the third day he " had a crifis," and was relieved. "He arrived at Laar, at day-break on the 27th, for they travelled by night only, on account of the exceffive heat. There he obtained the affiftance of the governor's phyfician, for the fever had returned wirh violence. The French furgeon and himfelf thought the cafe defperate, but the Perfian phyfician treated it as of no Gor.fequence, " You have," fiud he, gravely, " the fever of Bender, but do not be uneafv, for, with God's blefiing I will relieve you from it this very day."—Chardin called out, " I am dying of heat."—"I know it," faid he, "but you fhall foon be cooled." The phyfician prefcribed a great quan- tity of medicine, confifting of two enrmlfions, a cooling confeaion, and at lraft a quart of fome bitter decoaionor infufion, with four bottles of willow-water, and a tea-pot full of ptifan." Thefe arrived by an apothecary about nine o'clock. Chardin fwallowed the medicines with ex- treme difficulty and reluaance, but without apparent bene- fit. About ten his heat and thirft increafed rapidly, and the apothecary told him he fhould have been happy to have given him fnow-water to drink, but that fnow being fcarce, no one could procure any but the governor. <* As in the extreme heat of my fever," says Chardin, " I thought nothing could be so delicious as drinking snow-water, I sent to beg a little snow of the governor, who sent me some about eleven o'clock •, and as I then had the most raging thirst, I drank with more pleasure and avidity than I had ever done in my life. My apothecary was always near me. It was he who administered the liquid to me. He filled a large vase with barley-water and willow-water, put a large lump of snow into it, and when it was half melted, gave me the vessel, and desired me to drink my fill. The pleasure I had in drinking was the greater, because the li- quor was very agreeable to the taste, and I took it by the physi- 349 cian's desire. I was lying on the ground floor of the house, in a cool room, my bed stretched on the ground. Every hour the floor was wntered, so that it might be said to have been quite co- vered with water. But nothing could allay the heat of my ma- lignant fever, which seemed to be irritated rather than abated by so many cooling remedies. My apothecary then ordered my bed to be taken up, saying it heated me; and he spread a thin mat in its place, upon which he made me lie down in my shirt, with- out any other covering, and then made two men come and fan me. But this was of no avail, the heat continued as oppressive as ever. The apothecary who paid me the most constant attention, then procured two buckets of cold water, and having placed me on a chair, on which I was supported by two men, poured the water over my body by little and little, from the haunches down- wards, and then taking a large bottle of rose-water, bathed, in the same manner, my head, face, arms, and breast. I blessed, in my heart, the Persian praaice of medicine, which treated sick persons so voJ^tuously ! But our French surgeon, who was al- ways by me,i^uld not contain his indignation. ' The man is killing yoJuiSir,' said he to me in a compassionate tone. «What! bathe yoii^Rn cold water in the heat of a malignant fever, with a pint of emulsion, two pints of decoaion, and a pound of con- feaion in your beliy, with I do not know how many draughts of snow-water. Depend upon it,',added he, 'that instead of being very soon without fever, as he has promised you, your death will be the end of the business'—«I do not know what will happen,' answered I, «but at any rate I do not feel as if I were about to die, as you suppose.' Indeed at that moment I felt the heat within me diminish, and my senses return-, upon which, my apo- thecary having felt my pulse, said, « Your fever is abating.' It went off from that time so quickly, that by one o'clock in the afternoon I was quite free from it, even in the opinion of the French surgeon. He was quite astonished, and I was transported with joy. After having offered up my devotions to God, as to the first cause of my recovery, I said to the apothecary, that to complete my happiness I must see my physician. He will return, said he, by the time the medicines have operated. I took them, as I have said, at nine in the morning, and I had only since that time ex- perienced a kind of heaviness, which swelled me up very much without griping me, so that I imagined they would have no effea upon me, and that their efficacy was exhausted in my continued Sweating. But in a quarter of an hour afterwards a looseness seized me, and lasted two whole hours, without any pain or un- easiness. In the evening the physician came to see me, and I received him as a prophet, or as Esculapius himself. He had 35° learned from the apothecary how I had spent the day, and he or- dered me a mess of rice boiled in water, with cinnamon, and the bark of dried pomegranate, pounded together. I had taken no nourishment whatever for five days. « On the 28th, when I awoke, I was a little feverish, on which account the physician, when he came to see me, ordered me an emulsion of the cold seeds, (melon, cucumber, gourds, and pom- pions), and a dose of the confeaion, as the day before, recom- mending that L should eat raw cucumbers. These remedies were given to me at nine o'clock in the morning, and I did nothing all day but drink, most deliciously, willow-water, and barley-water, cooled with snow, eating raw cucumbers, water-melons, and pears. Verjuice, in considerable quantity, was put into the mess which I took at noon and in the evening, to give it an agreeable taste, and it most wonderfully lessened my thirst. " The next morning, the physician having found me still ra- ther feverish, ordered me medicines similar to those I had taken on the 27th. These purged me during the wtfk day with so much violence, that I had nearly sunk several jQlBfcUnder the effeas. The night was still worse than the day, anKkesed it in pain, with a violent increase of fever. My physicunWound me in that state, and, as usual, filled me with consolation -, for, after having felt my pulse attentively, he told me that he was going to give me some draughts that would carry off what fever remained, and deliver me from it entirely. This certainly took place, but I do not know how he accomplished it. I only know that about nine o'clock in the morning I took two pints of emulsion, with a large dose of confeaion, as on the preceding days, and half an hour afterwards a julep; after which I fell asleep, and when I awoke in the afternoon, my head was clear, I was without fever, perfeaiy tranquil, and, as I thought, entirely restored to health. " I was so much transported with joy, that I could not find utterance to my feelings, relying on the word of my physician, whom I thought an oracle, that the fever would return no more. " On the morning of the 31st he confirmed this opinion, and ordered me to live ten days together on chicken and rice, without any thing else •, jat the endrof which time he said I might live as usual. I asked him how many days it would be before I could pursue my journey ? He told me that two more days of repose would be sufficient, and that I might then set out on horse-back. He once more ordered me a great dose of emulsions and cordials as before. " On the first of June he came to see me for the last time, 351 saying, that I was not any longer in need of his visits; that he had ordered the apothecary to bring me the materials for ten emulsions, and to teach my servant how to prepare them; also a box of salts, and thirty-five drachms of cooling confeaion, of which I w^ts to take one drachm daily, when I awoke, and to drink after it a glass of water. He said it was to warm and fortify my stomach, which so many emulsions and cooling medicines had considerably weakened." On the 3d of June, Sir John Chardin proceeded on his journey, and experienced no relapfej and on the 17th he reached Chiraz, in a convalefcent ftate and ftill weak, but otherwife fo well that he left off his medicines.* The fever of Sir John Chardin was, no doubt, the bilious remittent fever, fo common in the Eaft-Indies, in various parts of Africa and America, and indeed in every part of the earth, where the heat is great, and the foil low and moift, as on the fhores of the.Perfian Gulph. It is worthy of remark, that he improved, while travelling ex- pofed to the open air and the dews of night: his cafe, in this inftance, corroborating the faas mentioned in pages 258 and 259, and the reafonings by which they are ac- counted for. The manner of applying cold in this cafe correfponds with the principles I have laid down. The Perfian phyfi- cian attacked ihe fever at the height of the exacerbation } he had in view the fubduing of the morbid heat, and perfe- vered till this was effeaed. The laxative medicines were no doubt of fervice in carrying off the morbid contents of the alimentary canal; but they feem to have been carried to excefs on the 29th of May, and to this circumftance the return of fever may be imputed. The bitter medicine was- no doubt a decoaion or infufion of fome vegetable, in its qualities perhaps refembling the ' inchona; and the cooling confeaion was certainly the celebrated mithridate, a com- bination of opium and aromatics, well known over the eaftern as well as the weftern world. Whether the fame treatment of fever as that defcribed by Chardin, has continued in Perfia down to the prefent * Vovages rlc M, le Chevalier Chardin, torn. ix. p. 2<>8- 352 times, I am not informed. • That a fimilar treatment pre- vails in the correfponding climate of Africa, appears from the information of Bruce. " Mafuah," fays Bruce, "is very unwholefome, as indeed is the whole co,ift of the Red Sea, from Suez to Babelmandel, but more efpecially be- tween the tropics. Violent fevers, called there Nedad, are very prevalent, and generally terminate on the third day in death. If the patient furvives till the fifth day, he very often recovers, by drinking water only, and throwing a quantity o' cold water over him, even in his bed, where he is permitted to lie without attempting to make him dry, till another deluge adds to the firft."* The expreffion ufed here would lead us to fuppofe, that the external ufe of cold water is not reforted to unlefs the patient furvives to the fifth day. If this be the cafe, fome miferable theory, fuch as the doarine of concoaion, or of lentor in the blood, has probably penetrated among thefe poor Africans, to perfuade them that this remedy is not to be ufed in the early ftages of fever, thus limiting and almoft deftroying its efficacy, and counteraaing the evident indications of nature. Bruce defcribes the fame fever as prevailing in Abyffinia, efpecially in all low, marfhy grounds. " It is really," he fays, " a malignant tertian. It always begins with a " fhivering and head-ache, a heavy eye, and an inclination " to vomit. The face affumes a remarkable yellow appear- " ance." This is doubtlefs the yellow fever of the Weft- Indies and America. In Abyffinia as well as Nubia, the internal and external ufe of cold water feems to be reforted to freely in this fever, and with happy effeas. When we fpeak of the cold water of thofe uniformly fultry regions of the world, we ought not to forget, that the water even of their fprings, being never much colder than the air, is, in general, equal in heat to that of the Buxton bath, and rifes of courfe to what we denominate tepid in the climate. At Mafuah, Bruce found the mercury in Fahrenheit's thermo- meter to range from 83 deg. to 92 deg. which gives ftill higher medium temperature, (the probable temperature of the fprings), and hence he feems juftified in his advice to the * Bruce's Travels, vol. iii. p. 35. 353 traveller of Nubia, never to fcruple throwing himfelf into the coldeft fpring he can find, whatever may be his heat. It is owing to this high temperature of the water, that fatal accidents, from the improper ufe of cold drink or the cold bath, have feldom or never occurred in thofe countries, and that the external and internal ufe of water in fever has continued from age to age. The fuccefs of the external application of cold water in fevers, in the neighbouring countries, and in fimilar cli- mates, would lead us to expea a correfponding fuccefs in the fevers of India. It is not, however, to be concealed, that Mr. M'Gregor, whofe communication refpeaing the difeafes in Egypt, I have quoted fo largely, does not con- firm this expectation. In the concluding part of that com- munication he obferves, " in the fever moft common in " India, the cold bath did not fuccecd with me. On my " arrival there I tried it in feveral cafes, but it failed. This " fever is commonly of the remittent type $ there is much " reaaion; it feems in moft cafes to be fymptomatic of " liver affeaion, and often terminates in hepatitis." Where fever originates in congeftion of the liver, or any of the other vifcera, as no doubt it often does both in the Eaft and Weft-Indies, its cure cannot be expeaed from the cold af- fufion, which may not, even in fuch cafes, be fdfe. But with every refpea for Mr. M'Gregor, I can fcarcely doubt, that in the idiopathic fevers of the Eaft-Indies it will be equally fuccefsful as in other regions, due regard being always paid in adminiftering it to the ftage of the fever and the temperature of the patient. " I remember," says Dr. M'Lean,* " when in the East-Indies, on board the Airly Castle Indiaman, some eases of remittent fever occurred at Diamond harbour, where the company's ships an- chor. Several perished in spite of every atten ion One of the patients, however, in a fit of delirium, jumped out of one of the ^ports. He was immediately picked up, rubbed dry, and put to bed. His senses returned instantly, his pulse became more re- gular ; he fell into a profound sleep, and next morning there was .1 complete remission. He recovered afterwards very speedily. * Inquiry into the nature and caufes of the s;reat mortality among the. troop» at St. Domingo, by He&or M'Lean, M. D. p. 148. 45 354 " I recollea another instance perfeaiy similar, on board the Princess Amelia East-Indiaman, in the same place. The remittent fever had carried off more than half the ship's company, though every assistance, every comfort the sick could have, was procured by Captain Millet, the humane commander of the ship. A seaman of the name of Davies, a very stout, athletic man, in whom the remittent fever had at times alternated with epilepsy, jumped overboard; at the moment he did this an alligator was along-side the ship. He seemed to become at once sensible of his danger,* and swam with great vigour till he was assisted. I saw him the moment he came on deck; his countenance, which was before grim and unpromising, assumed a more mild and temperate aspea; his pulse, which had been extremely quick and feeble, was now slower and fuller; and his recollection, which had been confused and indistina, became clear and accurate. I direaed him to be washed over with brandy and put to bed. He fell into a profound sleep, which terminated in an universal perspiration, warm and profuse. The consequences were a very distina remission and speedy recovery. " These cases made a strong impression on my mind, and I was determined to take an opportunity of imitating a praaice which accident had pointed out. I had not then seen the book of my friend Dr. Jackson. An opportunity was soon furnished. Up- wards of thirty men were in my ward at the Diamond harbour hospital, and I commenced dashing buckets of water over them from some height; but whether the water was not sufficiently cool, or the patient being in espeaation, did not feel the shock, or that the circumstances were really different, I do not know, but I was by no means so successful as I had hoped from the two cases I have just related." The two firft cafes fuffkiently demonftrate the power of the cold bath in the fever of the Eaft Indies, when pro- perly applied. The patients did not theorize on the fub- jea, but obeying the inftina of nature, jumped into the fea in the moment of delirium, when the heat and thirft were at the height. (See p. 315, vol. ii.) Suppofing the principles which I have laid down for the proper admini- ftration of this remedy to be well founded, the candour of • Dr. M'Lean has enabled us to explain why he was com- paratively unfuccefsful in his ufe of it on fhore. The thir- ty cafes in the hofpital muft have been in different ftages * The plunge had reftored his intelktt. J. C. 355 of their progrefs, but he feems to have employed it in them all indifcriminately, and on a great part of courfe improperly ; or, if he feleaed his cafes, (which there is no reafon to fuppofe), his principle of feleaion we may fafely infer was*a bad one, fince the following are the direaions he lays down for the ufe of this remedy a few fentences af- terwards. " In the very early ftage of fever, before it has eftablifhed its peculiar mode of aaion ; before the re-ac- tion begins, I think the praaice of dafhing cold water on the patient may be ufeful. But after the fever has eftablifhed its peculiar mode of aaion ; after the cirmla- lation and veffels re-acl, after determinations to particular organs have begun, I hold this praaice lefs certain." There is another ftage of fever in which Dr. M'Lean thinks it may be ufed. " In cafes where the fenfibility is much impaired, where the recolleaion is confufed, where the fyftem is as it were oppreffed, and wants energy to re- move the oppreffion, where the pulfe is feeble and frequent t in luch cafes, I hold the dafhing of cold water to be one of the beft and moft powerful remedies." Again, " I am of opinion with Dr. Rufh, that it will be moft ufeful where there is greateft diminution of the nervous energy." The language of Dr. M'Lean is not very precife, and the direaions are not perhaps perfeaiy confiftent with each other. But it would feem, that he prefers the ufe of the cold dafh in the firft or cold ftage of fever, before the re-aaion and febrile heat begin ; or in the latter ftage, when the vigour is decayed, and the heat finking the precife fituations in which I deprecate its ufe. I cannot, therefore, be furprifed at the following declaration, which certainly rcfiVas honour on his candour: " We have much to learn from experi- ence on this fubjea. It muft not be concealed, that 1 have employed it often without fuccefs, in cafes where 1 promi- fed myfelf much from its ufe." Like his friend Dr. Jack- fon, Dr. M'Lean afcribes the beneficial influence of this remedy, wholly to the effeas produced through the me- dium of fenfation, and overlooks the changes which it oc- cafions on the living temperature by which the febrile mo- tions are fo effentially effeaed. Dr. Jackfon, like Dr. M'Lean, was led to employ the 356 cold bath in fever, by hearing of the fudden and extraor- dinary recovery which had occurred in the cafe of fome feamen, who in the delirium of fever, had thrown them- felvt-s into the fea* at the Havanna. This, he informs us, was communicated to him while he refided in Jamaica, fo eaily as 1774. It does not appear however that he adopt- ed fully this bold praaice, either in form or fubftance. He ufeJ the method of affufion, but as it fhould feem par- tially, on the head and fhoulders only. The effeas were falutary ; but he obferves, that he did not carry the prac- ticed far, that the fever could in any inftance be faid " to be precipitately extinguilhed by it," which is indeed a fuf- ficient proof of the lim ted manner in which the remedy muft have been employed. In 1798, a year after the firft edition of this publication, Dr. Jackfon gave to the woild, his Outline of the hiftory and cure of fevers. In the interval between this and his former woik, his experience of the remedy in queftion had extended, and his ftile and mode of reafoning had under- gone a remarkable alteration. I do not profefs always to underftand the full import of the new phrafeology of Dr. Jackfon, which is in a confiderable'degree founded on opi- nions peculhr to himfelf; nor do I, after a diligent com- parifon of his precepts with his praaice, perceive clearly the principles whit h regulated him in the ufe of this powerful remedy. I can, however, clearly fee, that there is little or nothing in common between us in this refpea. Inftead of employing the cold bath in the firft ftages, when the fheigrh is nearly entire, and the febrile heat at its height, he premiied copious bleedings and other evacuants, by which both muft have been previoufly reduced. Inftead of confidering the heat of the patient, as the principal cir- cumftanct to oe regarued in regulating the ufe of this reme- dy, he appears to have negleaed all confiderations of temperature in applying it, except in fo far as temperature is conneaed with fenfation j and he has not given us a fingle thermometrical obfervation in the whole details of * A treafife on the fevers of Jamaica, notes at the end p. 74, by R. Jackfon.-M. D. 1791. J 357 his praaice, either in regard to the water employed, the previous heat of the patient, or the change produced by the affufion. The previous or fubfequent drynefs or moifture of the fkin, forms no part of his confideration, and even the very remarkable and almoft uniform effea of this re- medy, on the pulfe, is entirely unnoted. Nor have I the fatisfaaion of agreeing with Dr. Jack- fon, on the manner in which the fenfibility of the patient ought to influence us in the ufe of the cold affufion. He requires a high ftate of excitement, or of fenfibility, on the furface in the application of this remedy, and confiders its benefit as wholly dependant on this previous condition; whereas an extreme fenfibility to impreffions of cold, (which according to my experience, often attends general fenfibi- lity of the furface in fevers), deterred me from employing it, even when the aaual heat of the patient indicated its ufe. It would not become me to pronounce judgment on the very important differences between Dr. Jackfon and my- felf; this muft be left to future obfervers. But from the experience which I have detailed, I cannot be furprifed at the impei fea fucceffes of the remedy in his hands, or that other praaitioners in the Weft Indies, who had adopted it on the lame or fimilar principles, fhould have afterwards abandoned it.* * In his Remarks on the conftitution of the medical department of the Bri- tifh army, publifhed in 1803, Dr. Jackfon has again entered on the treat- ment of fever, and on the ule of bathing as a remedy, at confiderable length. On this occafion he ment'ons my name, as having, by " the popular manner in which I have treated the fubjeit," drawn fome notice to the remedy ; but claims to himfelf the merit of having ufed it for 30 years, and of having communicated it to the world, as it would appear, the firft of our countiy- men, in 1791. Here, as in his two former publications, Dr. Jatkfon unac- countably neglefts to introduce the name of Dr. Wright, who, from MSS. in my poffeffion, unqueftionably ufed the cold affufion, in fmall pox, feveral years before 1774, and who communicated, for publication, his remarkable narrative, with which this work commences, to the Medical Society in Lon- don, in 1779. This moft important narrative, in confequence of accidental circumftances, was not inferted in the only volume of the Medical Obferva- tions and Inquiries, afterwards publifhed by that fociety, but was recovered from among their papers in 1786, on Dr. Wright's return to Europe, and given to the world in the widely circulating journal of Dr. Simmons, in that year j five years, of courfe previous to the firft publication of Dr. Jackfon. 35« Of this number, was my' friend Dr. Ord, of Demerara. I had feen this gentleman in Liverpool, in 1795, then on his way to the Weft Indies, and had mentioned to him ge- nerally, but not, it fhould feem, with fufficient preciiion as to the mode of applying it, the great fuccefs of the cold bath in fever. Dr. Ord obferves in a letter to me, that he did not conceive the principle on which I ufed it, was to procure the folution of a febrile paroxyfm, but to affift with other tonics in reftoring ftrength to the conftitution, after the febrile catenation had been removed. " After the embarkation of the troops," says Dr. Ord, " from that fatal island, (Spike Island, near Cork), where so many brave fellows suffered from the inclemency of the weather, and from which were brought the seeds of disease, that carried thousands more to an untimely grave in the West Indies, I made frequent trials of the cold.bath, on the principles already mentioned, but little good effeas were discernable. Again in this colony, (De- merary), when a dreadful fever baffled every other remedy,*I made ample trials, with as little effea. A stop was given to eve- ry further trial, by the effeas of the cold affusion, on myself in December, 1796. I was attacked by a double tertian, which ha- ving long resisted the free use of the bark, I employed the cold affusion very liberally. Syncope was induced, and on my reco- very by means of volatiles and friaions, I felt an intense burning heat, which was succeeded by an infinite number of white patch- es, exhibiting the appearance of urticaria. Great languor and debility supervened and no sweating stage followed. I recovered from the disease at length by means of a sea-voyage. " From the perusal of your valuable publication, which the honourable K. H. Mackenzie put into my hands, soon after my recovery, I became sensible, that I had misunderstood the laws In the remaiks above referred to, Dr. Jackfon defends his doctrines re- fpr&ing the ufe of cold bathing, in fevers, with fome feeming mo lificaiions. He now confiders " the prefence of li^at (i.e. morbid heat) in the patient, however produced, as a general index of forming a judgment of the refult,' but this obfcure expreflion does not mean, that when prefent it indicates the ufe of the remedy, or that its abfence prohibits it. Dr. Jackfon occupies feveral pages in controverting the rules I have laid down for the application of cold to the furface, and in laying down others of his own. Experience muft decide between us, and to that I appeal. If I were inclined to enter into any thing like controveify with him, 1 fhould foon find myfelf involved in that obfcurity with which his peculiar phrafeology inverts every med.cal fubjeel on which he treats. 359 by which the affusion ought to have been regulated, and it proves to me, (a melancholy refteaion), that I have too often seen the fatal effeas of its improper application. I have since trod on sure ground, and to a late use of the remedy in my own ease, in an- other attack of fever, I ascribe my preservation. " Towards the end of July, (1799), being exposed to much fa- tigue, and also to contagion, I suffered a very severe attack of fever, attended with some unfavourable symptoms; as great irri- tability of stomach from the first attack •, violent head-ache, with inflamed eyes; excessive restlessness •, much general yellowness, with vibices on the breast; and on the fifth day, an almost total deprivation of consciousness. Blood-letting, mercurials, antimo- nials, blisters, and bark, both by the mouth and by clyster, had been employed with little effea. On the morning of the sixth day, I was sensible, and conceived my death fast approaching. The heat of my body was insupportable, and I made myself so far understood by my attendants, as to request to be bathed, I was placed in a tub, and four gallons of cold rain water taken out of porous earthen jars, of the temperature of 74 deg, (as I have since ascertained), were thrown over my head and shoulders. The most grateful change was produced by the shock, I was mo- ved into bed, and slept about half an hour. Again the heat of my hands and feet distressing me, the affusion was repeated with the most marked success. I recovered my consciousness perfeaiy, drank half a pint of claret, and fell asleep. I will not tire you with useless repetitions; I resorted to the affusion as often as the heat returned, and with similar effeas; I was soon convalescent, and recovered favourably. " I am fully persuaded that the cold affusion is one of the hap- piest remedies ever recommended for fever, at the same time that it is highly grateful to the patient; nor so far as I know, does it stand in the way of any other remedy ; for under salivation I em- ployed it in my own person without detriment. I know indeed that it calls into aaion the mercurial disease, and that it may be employed with safety, as an auxiliary to that invaluable remedy, mercury." The letter of this amiable and accomplifhed phyfician, from whom I quote, dated Jan. 1800, contains a variety of other important obfervations, and was accompanied by feveral other cafes in which the cold affi .fion had been ufed in fever, with the fame happy effeas. In thefe all the par- ticulars requifite for accurate judgment are detailed with the greateft perfpicuity, and I am only prevented from in- 36o ferting them here, by the length to which this work alrea- dy extends, and the neceffity of haftening to a conclufion. The refult of the whole is, trfat in Demerary as in the other fultry climates of the earth, the cold bath is a moft valuable remedy in fevers : that in cafes a few days advan- ced, it requires to be again and again employed, and may be fo employed with perfea fafety ; and that, as in the fe- vers of fuch countries, vifceral obftruaions often attend fevers, fometimes in the relation of caufe, fometimes of effea, mercury is frequently required in combination with the cold bath, with which it may be conjoined, contrary to all former theories, but in correfpondence to the fafts mentioned in the firft edition of this work, not merely with impunity, but with the utmoft advantage. Thefe conclufions perfeaiy accord with the opinions of Dr. Chifholm, expreffed in the fecond edition of his Effay on the Malignant Peftilential Fever of the Weft Indies* already quoted in this work, vol. i. p. 193 and 202. Dr. Chifholm has expreffed himfelf on the ufe of cold bathing in fever with candour and liberality. " When I first began the use of cold bathing in these fevers," says he, " I conceived that the only periods at which it exhibited its beneficial powers, were the commencement, or rather before the fever is formed, and the low state, when the mercury has had no effea, and when the gangrenous disposition has begun its approaches. While this was my idea, I confess I could not sa- tisfy myself with any reasons why its operative effea should be confined to these periods. I could readily account, indeed, for the advantages derived from its early exhibition, (i. e. before the fever is fairly formed), by supposing the excitement of a new ac- tion sufficient to overpower the morbyd aaion before its establish- ment ; and the stimulant powers of cold clearly elucidated the benefits arising from the application of it in the low state. But has not cold a sedative power also ? And if it has, why may it not be applied to diminish morbid heat during the first stage, or * See Dr. Chifholm's Effay, fecond edition, vol. i. /. 457. See alfo the whole of his appendix, vol. ii. p. 461. The fafety and efficacy of the combination of the mercury and the cold bath in fever, are confirmed by the experience of Dr. Chifholm, and Dr. Armftiong of St. Kitts. For an account of Dr. Armftrong's practice, fee vol. i. p. 388-9 of Dr. Chif- holm's Effay, See. 361 the inflammatory state ? Authority, not experience, led me to avoid the trial j and such reasoning as the following confirmed my apprehension of danger from it. If we suppose that the opera- tive effea of cold is the produaion of a new aaion, which in one instance prevents, and in the other resists, that of the remote cause, how are we to expea, from it the removal of an inflam* matory diathesis, which stimuli have already excited ? This is spe- cious, but like most reasoning founded on theory, or badly ascer- tained faa, it is also fallacious. Dr. Currie, of Liverpool, first drew the veil aside, and exhibited the nature and cause of the fal- lacy. Defeaive observation and total ignorance relative to animal heat, in a healthy, and in a morbid state, I was convinced with him, were the true causes that cold bathing had hitherto produced but very partial benefit in the West Indies, during the inflamma- tory stage of fever in general." Dr. Chifholm regrets that this conviaion did not come earlier for the regulation of his praaice. His experience of the effeas of cold bathing, regulated by the principles which I have laid down, he gives in the 7th appendix to his fecond volume, to which I have already referred. The obfervatiorjs of Dr. Chifholm, were much extended in con- vention, when I had the pleafure of meeting him at the •houfe of a friend in the neighbourhood of Liverpool, in the fummer of 1803, and of finding, that moft of the opinions I had given, as well in regard to the prevention, as the cure of difeafes in the warm climates, were remarkably confirmed by the ample experience of this able and accu- rate obferver. A fimilar fatisfaaion I enjoyed in Liverpool, in Decem- ber, 1802, in the converfation of Dr. Macneil, Infpeaor- General of the hofpitals in Guiana. This gentleman com- municated the refult of his praaice with the cold affufion at Surrinam, in 1801; particularly in two cafe3, thofe of Mr. Mackenzie, paymafter of the 39th regiment, and of Captain Cameron of the fame corps, in which he employed the remedy to a great extent, and with a happy iffue. The particulars of thefe cafes I took down in writing, and would Certainly have introduced at large here, but for the rcafons which have obliged me to omit many other valuable com- munications. An abridged account I will however give. Mr. Mackenzie was in the 4th day of fever when Dr. 46 362 Micneil firft faw him, his bowels conftipated, his ftomach rejeaing every thing, and his ftrength finking fart. His bowels v\ere opened with calomel, and-his ftomach com- pofed by laudanum and asther, which alfo procured him fleep. On the 5th morning he was more compofed, and for the convenience of attendance he was carried by water in a covered boat, five or fix miles, by which excurfion he feemed rather benefitted than injured. He now took the bark, with faline effervefcing draughts, and a draught of laudanum and jether at night. On the 6th morning he was completely reftlefs and delirious, his (kin dry and burn- ing, with great thirft, and fenfe of heat. He continued his faline draughts and lemonade as drink, but threw them up, and at his own inftance he drank largely of cold water, that ftood by him, which feeming to agree with him, his whole furface wa^ fponged with it and afterwards dried. By thefe means his heat was much reduced, and his mind compofed. He was afterwards, at his own requeft, fre- quently fponged all over with cold water during the day and night, and he would not allow himfelf to be dried, but fuffered the moifture to evaporate, which he faid was in a high degree pleafant and cooling. In this wet ftate he would not allow even the fheet to lie upon him, but ftrip- ped off his fhirt and lay quite naked, that he might enjoy the breeze from the open windows, which blew over him. The heat of the day might at this time be from 84 deg. to 88 deg. In this way the fever was reduced, the delirium and agitation carried off, and the mind rendered calm and compofed. His ftrength was fuftained by bark and nutri- tious diet, his bowels were kept open by calomel and clyf- ters, and sether and laudanum given to render his nights tranquil. As often as the febrile heat returned, cold water was -employed internally and externally, as already defcri- bed, and always with fimilar effeas. In eight or ten days the difeafe was removed. The cafe of Captain Cameron, is ftill more remarkable. His fever was again and again removed by the ufe of the cold drink, and of the cold affufion, which he carried to the length of lying drenched in his wet clothes. But as he ■refufed all medicine and cordial nutriment, the fever re- 363 turned, in part probably from his continued expofure to the caufes which originally produced it. After each fucccrding paroxyfm his ftrength diminifhed fenfibly. At length the intermiffions became imperfea, delirium occurred, and the moft defperate fymptoms fupervened. He was finally faved by the ufe of mercurial inundtion, aether, laudanum, bark, and wine. " I think," said Dr. Macneil, " the cold affusion an admirable remedy for subduing the paroxysm of fever, and my experience of the time of using it, as well as of the other cautions, agrees with the rules laid down by you in the Medical Reports. But it is ne- cessary to follow up the advantage you obtain, with bark and nourishing diet, otherwise the paroxysm is apt to return, and though subdued again and again,'to return as before. I also in- cline to think, that in many cases the wetting of the whole sur- face, and allowing it to dry by evaporation, is less fatiguing and more safe, than the cold dash, especially when the patient has been weakened by the climate, or the progress of the disease. " I incline to think that the fevers of Guiana are contagious, though the constant ventilation of the habitations, which is en- forced by the climate, seldom renders this very striking or ob- vious. Abludons of the surface with water will no doubt render the operation of contagion still less. " The fevers of Guiana are not so violent as those of the wind- ward islands, and do not run their course so rapidly: the remis- sions in the first days are more distina. But if these are not taken advantage of, the fever becomes continued, and terminates gene- rally in eight, nine, or ten days. After apparent convalescence, returns are frequent, unless bark has been used. I have em- ployed the warm bath by immersion, with our soldiers, in the stages when the cold affusion could not be employed. It relieved head-ache, and assisted in opening the skin, but had not the per- manent or powerful effeas of the cold affusion. « Against the irritability of the stomach, the best preventive was keeping the bowels open. I wished my patients to have two stools at least a day, and even more seemed of use in some eases. Calomel given in quantity very frequently brought on vomiting, and I did not depend on it as a cathartic without its being com- bined with jalap, or the cathartic extraa. Where I wished for the specific effea of mercury, I preferred employing the ointment by inunaion. « Physicians in the West Indies, have gone from one extreme 364 to another in regard to the bark. Formerly they began with k immediately, without waiting for remissions. And this not suc- ceeding, they often abandoned it entirely and flew to other means. I was attacked with fever myself, but a smart cathartic produced a remission, when I threw in the bark largely, which prevented a return. To me it seems an admirable remedy, but it must not be used till the morbid heat is subdued, and the skin opened. Ca- thartics and the cold affusion produce these happy effeas, and then the bark should be thrown in as fast as the stomach will bear it. " The same caution should be used as to wine. It should not be employed in the first stages when the febrile heat is great, and the skin dry, but after the heat is in some degree subdued, and the skin opened, it is of great advantage. " Neither do I ever give opium in the first stages of fever. It is of the utmost consequence to keep the bowels free, to lessen the heat, and to open the skin, but these objeas obtained and en- sured, opium is of great use in allaying irritation and procuring sleep. It may also be used with advantage in the paroxysm of fever when the hot stage is declining, and the sweating stage has commenced. " I never found it necessary to give more than an ounce of the bark in powder, or even boiled into a decoaion, in the twenty- four hours. I generally combined it with rhubarb in the early Stages of its use, unless the bowels were opened by other means. I was always desirous that my patients should have several stools during the first stages of taking the bark. " In Guiana, fevers are most severe on Europeans newly arri- ved. They are brought on by intemperance, by fatigue under the heat of the sun, and by exposure to the rain, or evening dews, after the body has sustained the burning heat of the day. In short, all debilitating causes predispose to them. The country is low and swampy, the dews of night are very heavy, the exhalations from the rivers, canals, and ditches, very considerable, and load- ed with miasmata. Fevers there, generally begin with a rigour, but not always j head-ache, great heat, dry skin, pains across the thighs and the small of the back, and in some cases cramps in the Calves of the legs, may be considered as the general symptoms. " The-water used in Surrinam, is excellent. It is rain water, colleaed in cisterns under ground, and suffered to depurate. It is afterwards passed through a filtering stone, and kept in evapo- rating earthen jars, there manufaaured by the Indians, in which 365 h acquires a temperature from eight to ten degrees lower than the atmosphere.* Thefe obfervations of Dr. Macneil on the proper reme- dies in fevers, accord entirely with my opinions, and I earneftly recommend them to the attention of medical praaitioners, in warm climates, and particularly in the torrid zone. It was alfo my good fortune to become perfonally ac- quainted with Dr. James Robertfon, furgeon to the naval hofpital at Barbadoes, when on a vifit in Liverpool, in the winter of 1799—1800, and to receive feveral valuable communications from him, after his return to the Weft Indies, one of which is inferted at large in vol. i. p. 201, of this work. A letter from him, dated the 16th of March, 1801, contains a valuable differtation on the fevers of the Weft Indies, which I regret th »t I have it not in my power, for the reafon already repeatedly mentioned to give at large. I cannot however retrain from making extraas of fuch parts of it as more immediately refpea that mode of treatment of fever which it is the principal objea of this publication to explain and to enforce. " Till I read your book, and learned the result of your expe- riments, and the principles on which the effeas of the cold affu- sion were explained, I never had had recourse to it. For soon af- ter I came to this island (Barbadoes) in 1793 or 1794, a gentle- man lately from Europe had the cold affusion tried upon him after all other expedients had been resorted to in vain ; but he died during the operation, or shortly after it. I did not see the case, but have no doubt that the powers of life were too much reduced at the time the remedy was tried. The catastrophe made some'noise at the time and put a stop to the praaice. It however had been previously resorted to at different times by our praaitioners, or others, but always I believe as a last resort. In one case a gen- tleman of the name of M——e, ill of fever, was despaired of by his physicians. He was yellow all over, and had been delirious for some days. He had incessant vomiting, with hiccup, and pe- techia had spread over his body. In short, his dissolution seem- ed fast approaching, when General P----, determined to try the following experiment. The sick man was stripped naked, and • Thefe obfervations I took down from Dr. Macneil, in converfation. They were afterwards revifed by him. h C, 366 fresh lime-juice poured copiously over his body, friaions being at the same time employed. He was afterwards dried and put to bed. A general sweat broke out, followed by refreshing sleep. He recovered, and is alive at this day. I have not been able to learn the state of the surface as to heat at the time this remedy was tried." Dr. Robertson observes, that in the use of the cold affusion he has conformed to the direaions I have laid down, of which from experience he gives his decided approbation. • " I am frequently called on board merchant ships," says he, " to prescribe for men who are ill of fever, and as it is often inconvenient to send them on shore, I have frequently succeeded in extinguishing fevers in the first instance, by the affusion of cold sea-water on board. The patients are well dried and rubbed after the affusion, and lodged in a dry part of the ship. Two or three pills of calo- mel, of two grains each, are given at intervals of an hour, and an opiate, with some mild diaphoretic, is exhibited at bed-time. The cold affusion is direaed to be repeated, whenever they feel the sensation of burning heat return, with a dry skin, of the appli- cation of which simple^ rtle the master or mate is always a com- petent judge. " When patients are received at the naval hospital from ships of war, they are generally bad cases, whatever be the nature of the disease, as by the rules of the service, none are to be sent to the hospital who can be cured on board. Hence it does not often happen, that I receive cases of fever from our ships of war in an early stage of the disease, and the fe*cr-patients sent to the hos- pital often labour under other affeaions, which forbid the use of the cold affusion. But every patient in fever, as soon as recei- ved, is sponged with vinegar and water all over, before he is put to bed, if he feels hot, and the cold affusion is had recourse to af- terwards if the case seems to require it. " With prisoners of war the case is different. The sick of this description are under my care from the first, and as soon as any in jail appear to be in a feverish state, they are sent to the hospital. A part of the discipline of the hospital has all along been to wash the patients on their first admission, before they put on their hospital dress. And sometimes I have sent men back to the jail in a few days, without administering any other remedy than this ablution; the change of air, diet, and lodging, no doubt materially tending to arrest the progress of the disease " The cold water used by me in affusion has seldom been be- low that degree of temperature to which you give the appellation of cool, (74 deg. or 75 deg. of Fahrenheit), and I am apt to be- lieve, that that degree of temperature in this country is equally 367 efficacious with a much lower degree in a cold country ; for the sensations of the body are more acute, the fibre is more irritable in this country than in Europe, of which faa I have very recent experience in my own person. " The cool affusion, to adopt your relative term, may be consi- dered as cold in this country, and I consider it to be not only ade- quate to the desired effeas, but more applicable to cases of fever here, at least among natives, and long resident inhabitants, than the absolutely cold affusion ; though in certain cases, especially those of new settlers from Europe, this last might perhaps be preferable. I have however found, so far as my experience ex- tends, the medium temperature of our seas and springs sufficient for every purpose.* " And in cases where, from local affeaions or other circum- stances, the cold affusion is not judged expedient, milder modes of the application of cold have been adopted. Such as the spon- ging with water and vinegar; the lavatio frigida of Dr. Wright -, frequent bathing of the hands and face in cold water; dipping the face into cold water; chafing the wrists, hands, neck, and tem- ples, with camphorated ^inegar or spirits, and the application of the cold fresh leaves of the sand-box tree, or cephalic vine, about the temples, and rubbing the arms with lemons, or limes, cut transversely. " Indeed the salutary effea of calomel, and James's powder, where the latter is admissible (the state of the stomach, in this country, frequently prohibiting the use of any preparation of an- timony) may in a great measure be referred to their coaling effeas; for these medicines, by opening the bowels, and inen^ing per- spiration, must tend to prevent the accumulation ofWorbid heat, as well as by removing congestions, on which the febrile heat de- pends. And I have never found it expedient to continue the use of either calomel or antimonials, in fevers, after the skin becomes soft, the tongue moist, and the belly open, unless with a view of preventing or removing topical affeaions of the viscera, which I am confident that bark, either too early or too copiously ad- ministered, is apt to give rise to, or to confirm.". To Dr. Robertlon I am alfo indebted for fome com- munications, made to him by Dr. Davidfon, of St. Vin- cent's, of which the following is an abftracl: * " The temperature of the fea-water here, (Barbadoes), at and near the fiiore, is about 77 deg. or 78 deg". in. the heat of the day. But if che water be contained in a re- ceptacle, and expoled to the fun, the tempe:ature is fometimes higher. About fun-rife, the coo eft time of the d.iy, the fea on the fhore is about 72 dc-2. v.hi.h is nearly •«• heat of deep weils and fpn:..,s in fhaJv fituations." 368 " In 1791, and 1792," says Dr. Robertson, we had at St. Vincent's a low nervous.fever, which evidently seemed to be the offspring of contagion. It began in the small island of Beguia, and it was alleged there to have been brought from Guadaloupe. One of my patients brought it from Beguia, and died on the 11th day. Soon after, a brother of Dr. French, of St. Vincent's, was attacked with fever. The remissions were at first very evident, observing the double tertian type. The usual evacuations being premised, the bark was thrown in, but without any good effect, as it disagreed with the patient's stomach. All his symptoms in- creased, with delirium, subsultus tendinum, quick low pulse, dry skin, and great heat. The cold bath was administered. After dry- ing the surface and putting the patient to bed, a dose* of tinchire of opium was given in warm wine and water. He got into a profound sleep, with profuse sweating, and next day was in a con- dition to take the bark. A repetition of the bathing completed the cure. " I had three other cases at the same period; two of which were attended by my lamented and much esteemed friend, Dr. Mackie, of St. Vincent's who despaired of their recovery. But the cold bathing proved successful in them all." In thefe cafes Dr. Davidson ufed cold bathing in the ad- vanced ftages of the fever. He however mentions, that the heat was ftill great, and the skin dry, and to thefe cir- cumftances his fuccefs is no doubt to be attributed. In the malignant yellow fever, which raged in St. Vincent's, and the neighboring iflands, in 1793, Dr. Davidfon changed his plani'orJ|d;iiiniftering the remedy, of which a more diftina account is contained in a letter, which he wrote ac that time, to Dr. Brown, of Baltimore, than in his letter to Dr. Robertfon ; and of which, as it is given in an Ame- rican publication of 1794, we fhall therefore avail our- felves. It appears, that Dr. Davidfon, having heard of the great mortality in Philadelphia, in,1793, from the ma- lignant yellow fever, thought it might be ufeful to com- municate his experience of the proper mode of treatment of a fimilar difeafe which had recently occurred in St. Vin- cent's. " I have obferved with uneafinefs and concern," fays Dr. Davidfon to Dr. Brown, " that an epidemical fever, nearly fimilar to that which we have had in this ifland, for 369 fix months paft, has appeared in Philadelphia. The dif- eafe, as it occurred with us, attacked with more violence, and proved more fatal, than I ever recollea to have feen in any other inftance, during a refidence of twenty-two years in the Weft Indies, and part of that time at St. Lu- cia, where I had an opportunity of feeing the fever among the troops, and failors, in all its forms. . , " Early in April, the yellow feveY made it? appearance, both on shore, and on board the shipping. The young, phlethoric, and those lately arrived from a cold climate, were caiefly affeaed. The inflammatory symptoms ran high. Blood-letting, blisters, and gentle and constant purges, answered at first; but in ihe far- ther progress of the disease, the weather still continuing hot, the marks of inflammatory diathesis became less evident and the pulse sunk on blood-letting. The vomiting did not appear on the first days, and sooner ended in black vomiting. We found it necessary to alter our praaice; but I must candidly confess, that till I adopted the use of cold bathing, under the circumstances which indicated a typhus type, our endeavours to cure the fever were attended with little success. In the inflammatory state the disease was more at command, but in the other, the irritability of the stomach was such that we could not use tonics. Neither bark, wine, nor opium, could be retained. Upon a general re- view of the ill success which attended the pradrice of the medical gentlemen in this island, as well as in Grenada and Tobago, I was inclined to try the effeas of cold bathing, which I had used with success in the advanced stages of remittent fever. At first I tried the effeas of cold bathing in the advanced stages of this fever also, but without success; but as every other plan equally failed, I began the cold bathing in the commencement. Warm tamarind tea, or cream of tartar and manna beverage, was given immediately after the application of the cold bath, to excite sweating, and to open the body, if this last effea was not already produced by clyster ; and the instant that a sweat appeared, bark, mixed with the beverage, was given in as large quantity as the stomach would retain, with- out paying any attention to the fever, or state of the patient's pulse. When, however, the stomach rejeaed the bark, and there appeared to be an increase of head-ache, heat, and other symptoms of febrile affeaion, I had again recourse to the cold bathing alone, which was commonly repeated evening and morning, till the patient was out of danger. / am happy to an- nounre, that this mode of treatment has been uttemld with the u:r,r,st success. The cold bathing seemed to take off trie determination 47 37° to the brain, to remove irritability, and to determine to the sur- face, for in every case, a plentiful sweat was excited.* Dr. Davidlon's narrative has not all the precifion that could be wifhed, yet it is fufficiently clear in the poinrs moft effential, and particularly in this, that in a fever of the moft fatal nature, where all the eftablifhed modes of praaice failed, and where the cold bath itfelf equally failed when ufed in the latter ftages, it was attended with the ut- moft fuccefs when reforted to in the commencement of the dif- eafe, and duly repeated as the fever returned. Unfortunately cold bathing had been already propofed, as a remedy for the fever of Philadelphia, in the beginning of the epidemic of 1793, by Dr. Edward Stevens, of St. Croix, j- Dr. Stevens recommended the ufe of the cold bath every morning, in the ftate of languor and laffitude, which ufhers in the difeafe, with a free ufe of Madeira wine, a gentle opiate at night, quiet and reft. " When the disorder has gained ground," says Dr. Stevens, " and become violent, and when the danger is imminent, the most unremitting exertions should be made by the physician, to miti- gate the symptoms. The nausea, and vomiting may be relieved by an infusion of chamomile flowerg, given frequently, until the sto- mach is sufficiently emptied of all crude matter ; small doses of a cordial mixture, composed of the oil of peppermint, and compound spirits of lavender, may then be taken until the fever abates. If, notwithstanding, the irritability of the stomach should still con- tinue, recourse must be immediately had to the cold bath, which must be used every two hours, or oftener, if the urgency of the symptoms should require it. After each immersion, a glass of * This letter of Dr. Davidfon to Dr. Brown, was by him fent to Dr. Cumming of Philadelphia, by 'whom it was communicated to Dt. William Currie, of ths fame city, who has publifhed it in a note to his "Impartial Review," of Dr. Rufh's "account of the bilious romitting yellow lever, in Philadelphia, in the year 1793." The letter of Dr. Davidfon, appears to be given chiefly with the view of fhowing the exiflence of a fimilar difeafe in the Weft Indies to what appeared in Philadelphia, and the probabi- lity therefore of this laft being imported. Dr. Currie makes no rema'ks on the prac- tice of Dr. Djvidlon, nor does it appear to have been imitated either by him, Dr. Cum- ming, or Dr. Brown. f The fame who publifhed a very ingenious inaugural differtation at Edin* burg, m 1777, " De alimentorum concoftione," in which are contained forre curious original experiments made on the perfon who swallowed (tones for his livelihood. 371 cold Madeira, or a little brandy, burnt with cinnamon, may be administered." Dr. Stevens goes on to order injeaions of bark and lau- danum, and fomentations of flannels wrung out of fpirits of wine. As foon as the ftate of the ftomach will admit, he propofes bark, wine, and nourifhing food, diffuading from purging, blood-letting, and every part; of what is called the antiphlogiftic treatment. " Upon the whole," says Dr. Stevens, " I may sum up this hasty outline, by inculcating the use of the tonic plan in its fullest extent, and by warning against the ill consequences of debilita- ting applications, or profuse evacuations in any period of the disease; the cojd bath, bark, and wine, a spacious well ventilated room, frequent change of bed and body linen, and attention to rest and quiet, will, in most cases, prove successful, and strip this formi- dable disease of its malignity, its terror, and its danger.* It appears that the plan of treatment propofed by Dr. Stevens, was in fome inftances fuccefsful. It was ftrongly recommended to the public, in a printed letter, from the celebrated Mr. Hamilton, then fecretary to the treafiry, he having experienced its-benefits in his own perfon.j- The plan of Dr. Stevens, was at firft adopted by Dr. Rufh. " I began," says he, " the use of Dr. Stevens's remedies the next day after my interview with him, with great confidence of success. I prescribed bark in large quantities; in one case I ordered it to be injeaed into the bowels every four hours. I di- reaed buckets full of cold water to be thrown upon my patients. The bark was offensive to the stomach, or rejeaed by it in every case in which I prescribed it. The cold bath was grateful, and produced relief in several instances, by inducing a moisture on the skin. For a while I had hopes of benefit to my patients, but in a few days, I was distressed to find that these remedies were not more effeaual than those I had previously used. Three out of four of my patients died, to whom the cold bath was administered in addition to the tonic remedies before mentioned."% In confequence of this bad fuccefs, Dr. Rufh was indu- * See Dr. Stevens's letter to the pref.dent of the college of Phyficians, of Philadel phia, dated September 16, i793, "'"<"«tea in Dr. Rufh'.; " Account of t'v. b,!W,s r-, snittinj fever, in Philadelphia, in 1753. f See Dr. Rufh's Account, &c. | See Dr. RuuYs Account, Sec. 372 ced to abandon the plan of treatment, of Dr. Stevens, and to adopt an oppofite method ;—the free \\\e of evacuants, particularly bleeding, and purging, to which he has given the name of the depleting fyftem. On the propriety of this fyftem, I do not enter, being moft unwilling to touch on the controverfies in which it has been involved; but I may be permitted to fay, that the cold bath, ufed according to the direaions of Dr. Stevens, could not, On the principles I have laid down, be attended with fuccefs except under the accidental occurrence of cir- cumftances which were not in his contemplation, and which his precepts would lead thofe who employed it, rather to avoid than to embrace. Inftead of recom- mending the cold bath in the firft attack of morbid heat, Dr. Stevens does not feem to advife it as a remedy, till the difeafe has " gained ground," and the " danger is imminent." If naufea, and vomiting, can be relieved by no other means, reeourfe muft be had to the cold bath, which is to be ufed every two hours, or oftener, if the neceffity of the symptoms (rhat is, the naufea, and vomit- ing) fhould require it. One can fuppofe, that in certain vigorous conftitutions, even fuch application of this reme- dy might be fuccefsful, but generally fpeaking, it muft be expeaed to be hazardous in the extreme. Its compa- rative fuccefs, and fafety, in the hand of Dr. Stevens, in the fevers of St. Croix, we muft afcribe to their being of a milder nature, and perhaps in part, to the warer of the fprings on the fhores of that ifland, being twenty de- grees warmer than in the wells of Philadelphia. In a fub- fequent publication of Dr. Rufh, we learn, that the u!e of the cold bath was afterwards abandoned by Dr. Stevens himfelf. " Dr. Stevens," says Dr. Rush, recommended bark, wine, and the cold bath, for the cure of the yellow fever of 1793, be- cause he had seen these remedies most effeaual in. the vellow fever of St. Croix, but he laid all these remedies aside, and chiefly relied on a salivation, in the cure of the fever, of ] 797, of Phi. ladelphia."* * Second addrefs to the citizens of Philadelphia, by B. Rufh, M. T) 1799- 373 Dr. Rufh, however, in the bilious yellow fever of 1794, ufed partial applications of cold water to the furface of the bodv, and alfo employed it in the way of clyfter, with good effeas -,^ but he did not refort to the general affufion, or pufh the remedy to the extent neceffary to reap its full advantages. On other occafions it has been ufed in the defbuaive fever which has prevailed in the great cities of America, particularly by Dr. B'aylis of New York j but fo far as I know, fimilar obfervations are applicable to the mode of ufing it in fuch inftances, as to that laid down by Dr. Stevens. It has in general been ufed as a ftimulant and a tonic, in the advanced ftage of the difeafe; no re- gard has been paid to the patient's heatj nor do I know that a fingle thermometrical obfervation has been made on this dreadful fever, by any of the phyficians of America. In my view of the fubjea, we are ftill uninformed in regard to the moft important particular conneaed with the hiftory of the difeafe. The firft edition of the Medical Reports had no influence that I know of, on the mode of praaice in Philadelphia, or New York, in the fatal epidemic of 1798. The praaice I had recommended met indeed the approbation of Dr. Euftis, of Bofton ;-f and the fecond edition of the work was abridged, and recommended to public notice, by a gen- tleman, in the diftria of Maine, formerly a member of the Britifh Houfe of Commons. J But in the middle ftates, where the mortality has chiefly prevailed, other modes of praaice have engroffed the general attention. The Medical Reports was announced, but neither reviewed nor analized, in the Medical Repofitory of New-York. From a recent number of this valuable publication, I however fee with pleafure, that the praaice I have recommended, begins to receive fome fhare of attention. The following is the ex- traa of a letter from Dr. Selden, and Dr. Whitehead, of Norfolk, in Virginia, to Dr. Miller, of New-York, dated * An account of the bilious yellow fever in 1794, by B. Rufli, M. D. f See his letter, dated November 21, 1798, p. 18, of the fiift number of the Medical and Phyfical Journal. \ Mr. B. Vaughan. 374 July 15th, 1802, and publifhed in the 6th volume of that Journal. After a general view of the caufes, and of the fymptoms of the yellow fever at Norfolk, in 1801, they proceed as follow. « The plan of treatment proposed this year was, in many res- peas, similar to that adopted in 1800, of which we have formerly given some account. The lancet, however, was more sparingly employed; calomel, in all cases, was liberally exhibited, both with a view to produce, in the commencement, a full and speedy evacuation, and afterwards also, in such forms as have been found to bring on most readily a salivation, which, in every instance, with us, as has been often noticed by others, was followed by the recovery of our patient. Where topical affeaions occurred, we had recourse to local remedies. Cupping, and veneseaion, were early employed, afforded frequently great relief. Neither theory nor experience warranted the early exhibition of the bark; we always deferred it till some change in the febrile symptoms began to appear, and the irritability of the stomach had abated. But under every form of treatment, numbers fell viaims to the dis- ease. In this junaure, being desirous of making every effort, we had recourse to a remedy we had last year tried in a few cases with some benefit, and now found attended, as far as it was car- ried, with unequivocal success. This was the liberal affusion of cold water, not on the plan prescribed by some of the writers of the West Indies, but in a mode similar to that recommended by Dr. Currie of Liverpool. " The first trials were made on young robust British seamen, and the good effeas of this remedy equalled our most sanguine expeaation. After the affusion of the cold water, the pulse was often thereby reduced thirty strokes in a minute, the burning heat of the skin was greatly lessened, and the thirst, head-aehe, and other uneasy sensations, were greatly alleviated. The patient generally found himself so much relieved and refreshed, after the cold bath, that he submitted, not only without reluaance, but with pleasure, to a repetition of it. « If called in on the first or second day of the attack, we first direaed a strong dose of calomel and jalap, in order to procure a full evacuation of the bowels, after which the patient was ordered to be carried on deck, with only a great coat thrown loosely around him, and three or four buckets of salt water to be poured on his head and naked body. The operation was repeated, when the febrile symptoms threatened to return with their former violence. Three times a day was usually sufficient. We rarely found it ne> 375 cessary to continue the use of the cold affusion longer than the fourth day; during which time the bowels were kept open by the occasional exhibition of a bolus of calomel. « From the great benefit experienced in the two or three first trials, we proceeded to recommend it with confidence. Of all those patients to whom we had an opportunity of exhibiting this remedy, on, or before ihe second day of the attack, we had the good fortune not to lose one: but after this period, when the fever had begun to sub- side, without symptoms of amendment," the affusion of cold wa- ter seemed only to hasten the fatal catastrophe. In no instance was it used without the exhibition of calomel at the same time, and we might have been inclined to ascribe to calomel, the merit of the cure that was accomplished, had it not failed with us, sometimes, under the fairest trials. " No disagreeable effea was produced by combining the use of calomel with the affusion of cold water; nor in a single instance did the mercury procure a salivation, although the discharge from the bowels was scarcely as great, as when it was used alone in the cure of the disease. But, in almost every instance which termi- nated favourably when the cure was trusted to calomel without the cold bath, some degree of salivation came on, and in such ca- ses the appearance of this discharge was beheld with pleasure, be- ing regarded as an infallible mark of safety. " It is with the fullest conviaion of the superiority of this plan of treatment, to any we have yet tried, that we record its effeas. The subjeas of our experiments were those in whom we found the disease to attack with the greatest violence in the first com- mencement, and to aa with the most fatal force on their consti- tutions. We shall attempt no theory of the manner in which the salutary effeas of cold bathing in yellow fever are produced, nor venture to recommend it as a certain remedy; but we think, that in the hands of a skilful and judicious physician, it may often prove a powerful auxiliary, in enabling him to combat the fatal effea of that dreadful calamity we have been describing." After the body of evidence which has been brought for- ward, and particularly after this narrative, 1 may perhaps, though a ftranger be excuft d for propofing a more general trial of the praaice recommended in this work, to the can- did and unprejudiced phyficians of America. Propofals for improving the method of cure of the deftruaive fever of that country, cannot be confidered as fuperfluous. " Four times as many perfons," fays Dr. Rufh, " were affeaed by the yellow fever of 1793, as in 1798, but the mortality 376 in the two years was nearly equal ;"* a melancholy, truth, which affords room for much ferious reflection. Nor has the fubfcquent experience of the American phyficians, dif- covered a mode of treatment, on which confidence reds. The great cities of America, are ftill dc ferted on the ap- pearance of the yellow fever, which excites every where alarm and difmay. The method of treatment which I have propofed, fhould not be rejeaed, as being one which has been already tried there, and found inefficacious. An at- tentive confideration of circumftances will fhew, that the former trials of the external application of cold could not, on the principles here laid down, be attended with general fuccefs; and that though ac times fuch trials may have fuc- ceeded, they muft on the whole have bee*! precarious and dangerous. The evidence here produced, fhows the fin- gular fuccefs of this application, regulated by thefe princi- ples, in febrile difeafes, in various regions of the earth, and more efpecially, in countries and climates, refembling thofe of the United States of America. That it will fuc- ceed there alfo, is a fair prefumption, which nothing but the refult of careful and continued experience fhould be allowed to overthrow; fince the evil is one, for which no other remedy has been found, and, fince it is of a magni- tude to obftrua the high deftinies of a people, otherwife moft happy and profperous. I venture thefe obfervations with hefitation, and offer them with deference and regard. An obferver at this dif- tance muft be particularly liable to error; and thofe who have performed their duty with courage and fortitude, amidft fcenes of unprecedented toil and danger, are entitled to the refpea, as well as the fympathy of their more for- tunate contemporaries. * Dr Rufti's fecond addrefs to the citizens of Philadelphia, publifhed jn 1799. Dr. Rufh imputes this vaft increafe in the propoition.ite mor- tality, to the defertion of blood-letting. Perhaps it may have been m■ • jjart, owing o the defertion or cold bathing, by which, though ufed at random, many feem to have been faved in 1793. 377 CONCLUSION. IT would not become me to conclude without fome notice of Dr. Wright, with whole important narrative this publication commences. This refpeaable phyfician, after having retired from the fatigues of his profeffion, had his fervices called for, onCe more, by Sir Ralph Abercrombie, and attended the laft Weft Indian expedition of that illuftrious and lamented commander, in quality of phyfician to the army. On his return to Britain, he landed at Liverpool, in June 1798, and I had then an opportunity of forming, not merely an acquaintance, but a friendfhip, with one to whom, while unknown, I had been fo much indebted. I found in Dr. Wright, an excellent phyfician and naturalift, who had devoted a long life to the purfuits of fcience, not in academic bowers, but in fituations of toil, difficulty, and danger; who had profited of *his ample experience by conftant and unprejudiced obfervation j who poffeffed a generotis and diftinterefted temper, and a fimplicity of manners, worthy of a more virtuous age. From that time he has refided in Edinburgh, and I have had the advan- tage of his regular correfpondence, and of his valuable ob- fervations. He has been uniformly zealous in promoting my medical purfuits, and to his, kindnefs, I owe the ac- quaintance of Dr. Macneil, Dr. Robertfon,and Mr. M'Gre- gor, by whofe communications I am fo much obliged. During his laft refidence in the Weft Indies, and while diredor of the military hofpitals in Barbadoes, Dr. Wright drew up for the Medical Board in London, a report on the difeafes moft common among the troops in the Weft Indies. In fpeaking of the cure of the (hip-fever, he ob- ferves, " in the beginning of the fhip-fever, the cold bath 48 37* had the beft effeas; and through the day, when the fick were hot, wafhing the hands and face fuddenly in cold water and vinegar, was exceedingly refrefhing." In like manner, in treating of the yellow fever, he remarks, " in the beginning of the yellow fever, the cold bath fucceeded adminbly, but in the advanced ftage, much caution was neceffa y." I quote thefe fentences from a report, the whole of which deferves the moft careful attention of mili- tary practitioners in warm climates, to fhow that the ex- perience of Dr. Wright, continued to juftify his original recommendation of the cold bath in fever, and to juftify in particular, the mode in which I had recommended it, at a time when my publication was equally unknown to him, as his report was to me. In a few months after his vifit to Liverpool, I received from Dr. Wright, his remarks on the fecond edition of the Medical Reports, much at large. In thefe, after fupporting all the principal parti of my treatment of fever and convul- five difeafes, from original'obfervations of his own, he con- cludes by affuring me, that my work has his unqualified approbation. In fubfequent communications from this venerable phyfician, he informs me of the fuccefs attend- ing his ufe of the cold affufion in febrile difeafes, in Edinburgh ; particularly in the late influenza, which he treated as a fever of debility, allowing a liberal diet, and the moderate ufe of wine, but keeping down heat and flufhings, by the fudden application of cold water on the furface; a mode of treatment which he found invariably fuccefsful; and he expreffes a confident opinion, that the cold affufion, well timed, will not only cure all febrile ex- acerbations, but prevent their taking place. " I agree," fays Dr. Wright, " with Dr. Falconer of Bath, in thinking, that the cold affufion will fecure perfons from taking the plague itfelf, though expofed to its contagion." In his different communications, this liberal phyfician gives me every credit for having afcertained more precifely the rules by which the application of cold to the furface mould be regulared, and particularly for the introduaion of thermometrical obfervations into the hiftory of difeafes, 379 a praaice before, either unknown or neglected. My ob- fervations on the change of animal heat, and particularly on the changes produced on it by cutaneous perfpiration, (the origin of which is given, vol. i. p. 174,) had prepared me for tracing the changes it undergoes in fevers, previous to the appearance of Dr. Wright's narrative, and led me infenfibly to detea that generally prevailing error of mo- dern times, that the application of cold to the body, ex- ternally or internally, is dangerous in proportion as the body is heated ; more dangerous therefore in fever than in health ; and moft dangerous in that ftate of fever where the heat is greateft. The deteaion of this error, neceffarily conneaed itfelf with a true theory of the principal funaion of the perfpiration, that of regulating the temperature of the body in health and difeafe; a moft important funaion, previoufly difregarded in the writings of our phyficians on fever, and wholly overlooked in the works of what are called the fyftematic authors in medicine, not excepting the lateft of them, Cullen, Brown, and Darwin.* That fome advantages are to be obtained from a ftria attention to the ftate of the heat in fever, and to the proper funaion of the perfpiration, this volume, now fubmitted a third time to the public, affords, if I do not deceive my- felf, important proofs. A careful attention to the changes of the animal heat, and to the ftate of thofe funaions on which it depends, and by which it is regulated, though more requifite in febrile difeafes perhaps than in others, is * This function of the perfpiration, or tranfpiration, had been equally overlooked by the phyficians of the continent. The chemical phyfiologifts did not wholly pafs it over. In vol. i. p. 189, the fpeculation of Franklin on this fubject is mentioned ; and in the yeai 1790, the celebrated Lavoifier read befoie the academy of fciences, a memoir on tranfpiration, tin- joint production of Seguin and himfelf, the principal object of winch is to ftitw, that this difchaige cools the fyftem, and regulates the living heal, which refpiration had produced. This memoir, with the other papers which con- ftitute the volume of the academy for 1790, the \A\ of the feries, was not published, in confequence of the revolution, fll 1797, and was wholly un- known to me till 1801, when the fliort-lived peace enabled us to obtain the pioilucts of the French prtfs. I was not a little grat.fied in finding that my obfervations on this fubject, on which I had built fo much, were fupported by fuch high authority. So f.r as I have been able to examine, no abftract or the memoir on tranfpiration wa* publifhed at the time of its being read, 01 before 1797, in any of the French journals. 38o however of importance throughout«the whole circle of dif- eafe. The capacity of the animal to preferve its heat nearly unchanged in the various changes of temperature of the furrounding media, is effential to, and may indeed be faid to conftitute life. Digeftion, refpiration, and perfpiration, thefe are the three funaions, on which the living heat, and life itfelf immediately depend, and by the relative aaions of which the juft medium of the animal temperature is preferved. To mark the various changes in thefe ftrictly conneaed funaions, and compare them with the aaual changes in the animal temperature in the different circum- ftances of the living fyftem, might appear a humble la- bour, becaufe requiring little but patience and attention. Yet on fuch a labour we can conceive that Bacon might have entered with alacrity ; in fuch a labour Lavoifier was aaually engaged : conduaed patiently and carried on per- feveringly, fuch a labour might terminate in the moft im- portant confequences; might give us juft principles of the effeas of temperature on life, and afte the fruitlefs wan- derings of the human mind for three thoufand years, might lead to a true theory of health and difeafe. In the progrefs of fuch an inveftigation, the effeas of different kinds of food on the aaual ftate of the living heat, and on the faculty of preferving .the healthy temperature, would come under examination ; the opinions fuggefted by falfe theory on this fubjea would be deteaed, and the re- gimen of diet be improved. The effea of different medicines on the animal tempera- ture would likewife be fubmitted to experiment; a new light would be eaft on their mode of operation; and more accurate rules laid down for their adminiftration. The conneaion between the ftate of refpiration and the aaual temperature, certainly not an obvious one, would probably be difcovered ; and that between temperature and perfpiration be diftinaiy and eafily traced. And, to pafs over a multitude of other fuggeftions that croud upon the mind, the queftion refpeaing the exiftence of that morbid ftriaure on the extreme veffels of the furface, by which perfpiration is at times impaired or obftruaed, 3^1 heat accumulated, and morbid aaion induced, would be brought to iffue, and one of the moft important of the phcenomena of difeafe, be in my judgment, clearly afcer- tain' d. But to fucceed in fuch an inveftigation, it feems necef- fary that the phcenomena of thefe different funaions fhould be examined, with a reference to each other ; by which each feries would be illuftrated, and the general refults rendered clear and certain. Leifure for fuch an inveftigation, even if the other qualities were not wanting, cannot be hoped for by one whofe time is much occupied, and whofe health is fo precarious. But under each of thefe heads, I have colleaed a few obferva- tions, which I fhall one day fubmit to the public, lhould my life be prolonged. In the mean time, returning to the more immediate objea of this publication, I fhall conclude with the following remarks. Though I am far from thinking that fever, properly fo called confifts merely of a feries of phcenomena, originating in a morbid accumulation of heat in the fyftem, yet this fymptom evidently occurs, more or lefs, early in that dif- eafe ; and it will not now, I think, be denied, that the fudden abftraaion of this heat, if done early, and without debilitating the patient, very often, if not generally, puts an immediate end to the pain ; and that even in cafes where the termination is not immediate, the fymptoms are by this means abated, and the fever brought to a more fpeedy iffue. The cold affufion fo far from being a debilitating, may indeed be confidered as an invigorating power, which by the fudden, general, and powerful ftimulus which it com- municates to the fyftem, deftroys the morbid ftriaure on the fkin, and reftores that procefs to its due aaivity, by which the future accumulation of morbid heat is prevented. It feems at the fame time to interrupt effeaually the aaions of fever, and to reftore thofe of health. Though the morbid heat be not confidered as the ori- ginal caufe of fever, yet it will be evident, on a flight con- fideration, that no remedy can ftop fever, which fuffers the 382 morbid heat to continue. I have found by experiment, what indeed might have been fafely inferred without it, that a heat, four or five degrees greater than that of health, however induced, cannot exift in the living body, without being attended by increafed rapidity of circulation, increa- fing debility, and all the principal fymptoms of fever. If this be true, the other remedies which have been fuppofed to flop fever in its early ftages, whatever their other quali- ties be, muft have direaiy, or indi.eaiy, the power of diminifhing morbid heat. Thefe remedies are emetics, fudorifics, and blood-letting, all of which 1 find, by expe- riment, are poffeffed of this power, though in different degrees. Without refering to the origin of the febrile heat, it may be laid down as a rule, that in febrile difeafes it isfo far conneaed with increafed vafcular aaion, that whatever reduces this aaion, reduces the heat. The naufeating, and debilitating effeas of antimonial emetics, produce this diminifhed vafcular aaion in a ftriking manner, and reduce the heat of the furface, as I have found by the thermome- ter, in a correfponding degree; and not of the furfact only, but of the whole fyftem, if the fenfation may be trufted. They alio increafe the cutaneous perfpiration, and ftop for a time, the febrile aaions. Sometimes efpecially when ufed very early, (for it is only in the firft ftages of fever that an- timonials are ufeful, or even fafe), they interrupt the difeafe effeaually. But much more generally, after the ficknefs paffes off, the fever returns, and returns to the frame very confiderably debilitated. If the remedy be repeated, the chance of benefit is diminifhed, and the debility greatly augmented. Antimonials are more debilitating than ipe- cacuanha; and remedies of this clafs are more fafe in in- flammatory, than in contagious fever. Sudorifics aa lefs powerfully than emetics. But when ufed early, and duly perfifted in, they are fometimes effeaual in ftopping fever; though more generally ufeful in alleviating its fymptoms. They are ufeful however only while the morbid heat con- tinues, or the difpofition to it exifts. That they aa by diminifhing this heat, is evident j but they alfo diminifh the ftrength. 383 Blood-letting is a ftill more refrigerating remedy, and feems only ufeful in fever when it produces this effea. It operates no doubt by the fudden diminution of vafcular ac- tion. I have fo feldo.n ufed it in contagious fever, that I cannot fpeak of direa experiments to eftablifh its cooling effea in that difeafe. But in inflammatory fever, and more efpecially in that conneaed with inflammation of the lungs, I have often obferved the rapid diminution of the heat as the blood flows, with admiration. Such experiments I have too frequently had an opportunity of making in my own perfon. In one inftance, where my heat was 103 deg. of Fahrenheit at the moment the lancet was introduced, and I watched, as ufual, the mercury of the thermometer, the bulb of which was grafped in the burning palm of my hand, after a few feconds I perceived it began to fall—at firft flowly—and afterwards rapidly. I faw it fink to the 91ft degree, I was then cold all over me, and my fore- head, and furface, were bathed in a clammy fweat—at this moment deliquium animi came upon me, but the bulb of the thermometer being ftill in my hand, my afliftant found the mercury to fink to 83 deg. before he could bind up my arm. On weighing the blood, it appeared that I had loft about eighteen ounces. I can conceive, that in fome fortunate inftances, the early ufe of this remedy may have ftopped the progrefs of -fever, or brought it to a fpeedier iffue. But that it has not ufually fuch an effea is certain, and the great debility which it occafions, muft impair, or deftroy the chance of recovery, where the fever proceeds in its courfe. In fome cafes, the moderate ufe of this remedy may have co-ope- rated with the cold affufion, but where the febrile heat can be removed by any mode of the application of cold to the furface, it is far fafer to truft to this alone. Of this laft remedy it can alone be faid, that while it fub- dues the principle of fever, it does not impair, but invi- gorate the powers of life ; that it may be repeated again and again with fafety ; that its application admits of precife rules; and that, while it is the moft powerful of the means of cure, it is the beft preventive againft the fpreading of 3«4 the difeafe. In the warmer climates, where the ftomach and bowels are fo liable to be affeaed in fever, calomel appears from experience to be the moft ufeful remedy, in combination with the application of cold to the furface. It operates, no doubt, by clearing the ftomach and inteftines, and thus removing morbid irritation, and abating morbid heat. It has been thought—though this is lefs certain— that the fpecific effeas of the mercury on the fyftem, are equally, or more important, and refpeaable phyficians have afferted, that where falivation could be produced in the yel- low fever, recovery was almoft always the confequence. It may be faid, perhaps, that where the power of the abfor- bents remains, and there is time for falivation to be effea- ed, the difeafe has been originally of a milder nature, and the recovery more probable from the firft. But I may alfo remark, what has not before been obferved, that falivation is accompanied by a more profufe perfpiration from the fur- face, a circumftance which may diminifh the febrile heat and irritation. By the help of obfervations fuch as thefe, we might, perhaps, be enabled to explain the contradiaory reports of the effeas of remedies by refpeaable praaitioners, in the rapid and deftruaive fever to which the Weft Indies and America have of late been fo particularly fubjea. But it is better to leave their application to thofe candid and ju- dicious obfervers, who alone are acceflible to the opinions of others, and capable of bringing them fairly to the ftand- ard of truth. Liverpool, 6th May, 1804. 385 CHAP. VI. , Additional Information refpetling the Ufe of the Cold and Tepid Affufion of Water in Fever, fince May, 1804. ABOUT the time that the laft fheet of the third edition of the Medical Reports was printed, (May, 1804), I received a letter from Dr. Barry of Cork, accompanying a copy of the annual report of the hofpital for fever in that city, entitled the Houfe of Recovery, in which a new and ftriking evidence in favour of fuch eftablifhments is given to the world. In the letter alluded to, Dr. Barry men- tioned to me generally, the great fuccefs which had at- tended the affufion of cold water, during the preceding year, in the praaice of that hofpital; and afterwards at my requeft furnifhed me with the details of twenty cafes of fe- ver, and three of influenza, in which he had trufted the cure chiefly to this remedy. The fame poft brought me a fimilar communication from Dr. Daly, the colleague of Dr. Barry, containing the particulars of nineteen other cafes of fever in the fame hofpital under his care, in which he had adopted the fame practice with equal fuccefs. At an early period of the hiftory of this remedy, I fhould have thought it my duty to have given thefe very fatisfaaory cafes in detail. After the accumulation of evi- dence on the fubjea of this praaice, that has been laid before the public, it will be fufficient to fpeak of them generally. The application of the cold affufion was regulated very exaaiy by the principles laid down in this publication. The effeas were on the whole fuch as former experience would lead us to expea. All the cafes terminated favour- ably. Dr. Barry laments that they had fo few opportu* 49 3«6 nities of ufing the cold affufion, within the period in which it ufually cuts fhort the difeafe. In fix of the cafes* however, detailed by him, and in four of thofe of Dr. Da- ly, " the progrefs of the fever was effeaually interrupted, and the patients were quickly reftored to healrh." In fome of tiie cafes thus cut fhort, the fever had exifted four, five, or even fix days; but the experience of Dr. Barry, and Dr. D.*ly, confirms the pofition, that the earlier the cold affuiion is applied after the morbid heat is eftablifhed, the bettu- the chance of the immediate termination of the dif- eafe. Even in the cafes in which the fever ran its courfe, from the remedy not being reforted.to in time, " the fymp- toms," fays Dr. Barry, " were confiderably mitigated, the patients feelings were rendered much more toleiable, and th* advances to health became more fteady and certain." The effeas of fhe cold affufion, in diminifhing the heat, in leffening the frequency of the pulfe, and in producing a difpofition to fleep, were fuch as have already been fo often defcribed. In two or three inftances, however, on apply- ing the thermometer after the cold affufion, Dr. Barry found the heat not diminifhed, but rather increafed, " though the pulfe had fallen, and the more diftreffing fymptoms were relieved." This relief did not in fuch cales prove permanent; the fever continued its courfe. The dread which fome of the fick had at firft of the cold affufion, feemed an obftacle to its good effeas. Un- der this dread the pulfe was not always reduced by it in frequency, and the patients fometimes trembled for a fhort time after going into bed. But when they became accuftom- ed to the fhock, which generally happened on the fecond or third application of the remedy, it had its ufual good effeas. The lavatio frigida, (wetting or fponging the furface of the body), was had reeourfe to, in a ftill greater number of cafes than the cold affufion, and with advantage. Its effeas, however, were much inferior to thofe of the cold affufion. The heat was feldom fo much reduced by it as to make any change in the pulfe, though the patient felt much relieved by-it. It was chiefly ufed in thofe cafes 387 which from weaknefs feemed unfit for the cold affufion. The auxiliary remedies ufed in thefe cafes, were chiefly calomel to keep the bowels regular, anodynes when re- quired, and in fome inftances a moderate quantity of wine. The cafes of influenza, (which are particularly detail- ed), occured in the fpring of 1803. The fvmptoms were of the moft violent kind. The cold affufion proved ftri- kingly falutary, in fpite of confiderable pulmonic affec- tion. The cold affufion has been ufed in feveral other parts of Ireland with fuccefs, but the particulars have not come to my knowledge. There is no doubt that it will prove equal- ly falutary there, as in the fifter ifland. It was my fate to fpend a confiderable part of laft win- ter (1804-5), at Clifton near Briftol. Accounts were re- ceived there in the month of January, of the appearance of a contagious fever of a malignant kind, among the French prifoners at Stapletort in that neighbourhood, and as is ufual in fuch cafes, its fatality was much exaggerated De- firous of offering any affiftance in my power to thefe un- fortunate men, I made a vifit to Stapleton, and called on Dr Teffcott, the gentleman who has the medical fupenn- tendance and care of the prifoners under the Board of Sick, and Hurt. Dr. Teffcott, was at that moment abfent on bufmefs, but on mentioning my name and the objea of my vifit, I was received with great civility by his affftanr, by whom I was conduaed through the hofpital for the fick. It contained at that time upwards of 200 cafes or typhus, in different ftages of their progrefs; each of the patients fa far as I obferved had a ieparate bed, and was comfortably provided with bed clothes and linen The arrangements refpea.ng food and medicine feemed liberal, and the attendance of every kind exceeded what might have been expeacd, on fo difficult and fudden art emergency. 388 The fever was evidently typhus, in a malignant form. In fuch patients as I examined there were, head-ache, dull, and fometimes blood-lhot eyes, much difturbance of the funaions of the mind, great proftration of ftrength, and very generally petechias. The pulfe was not very ftrong, in frequency it ran from 90 to 120 in the minute; the fkin was dry ; the heat various in different patients. I had not an opportunity of meafuring it, but it did not feem immoderate in any, the ftate of fever confidered. From the gentleman who accompanied me round the hof- pital I had every information I required, and Dr. Jeffcott himfelf who returned my vifit at Clifton, has been fo obli- ging as to give me a written anfwer to my queries fince the epidemic was fubdued. I am thus enabled to ftate the following pirticulars. The contagious fever was firft obferved among the pri- foners at Stapleton on the 10th of January (1805); the laft cafe received into the hofpital, was on the 20th of April. The whole number of cafes of fever, was eight hundred and fifteen, of thefe between three and four hun- dred were cut fhort by the cold affufion, many of them in the fecond, third, and fourth days of the difeafe. From four to five hundred ran their courfe, and of thefe forty- one died. The whole infeaious period lafted a hundred days, and the number received on an average into the hofpital, was rather more than eight daily. But the aaual number re- ceived in a given fpace of time varied much. It was greateft in the fecond and third weeks of February. On the 15th of that month, eighry-five patients were received into the hofpital, none of whom had any fymptom of dif- eafe upon them the preceding day at one o'clock, the hour at which all the prifoners were daily examined by Dr. Jeff- cott, and when all that complained were fent to the hofpi- tal. The fever attacked the old and young, but the^young more particularly. Thefe, however, almoft all recovered. The viaims were, chiefly men advanced in life, and of Nvorn out conftitutions. The fyftem of treament followed 389 by Dr. Jeffcott, I will give in his own words, extraaed from his letter to me of the 7th May, 1805. " Immediately on the patients being sent to the hospital, and before they were put into their respeaive births, they were put into the warm bath and soap was used to cleanse the skin effeaually. They were then wiped dry, clean linen was put upon them, and they were put into bed. There they were left in general two hours, when their pulse and heat were examined accurately by the watch and thermometer as direaed by you, and where the pulse exceeded one hundred, the skin being proportioriably hot, without evident marks of pulmonic inflammation, the patients were put into an empty tub, and two or three buckets of cold water, each contain- ing from three to four gallons, were dashed over their heads and bodies with the happiest effeas. This was repeated two or three times or more as the symptoms indicated. About four hundred were effeaually cured in this manner, some of whom were free of fever on the 2d, 3d, and 4th day. In the advanced stages in- -*>stead of the affusion, the body was sponged all over three or four times a day. « Salines, calomel and wine were given during the fever, as required, and bark in the convalesent stages. " I had frequently in the course of my praaice on board ships of war, experienced the good effeas of the cold affusion, as re- commended by you, and was therefore prepared for its use in this epidemic. The French prisoners were at first offended at being sluiced with cold water, but they soon called aloud for it. Their continual cry was, " Les Anglois coupent la fievre a l'instant par le moyen des bains fraids." « One symptom which occurred toward the latter end of the disease, where it ran its course, was a livid colour of the feet and toes, which afterwards became sphacelated in spite of every stimulant that could be applied to the part or given internally. " The cold affusion or immersion was not used as a preventive to prisoners in health. Five of the attendants on the hospital caught the fever, two of whom died. " I fumigated the wards of the hospital continually with the muriatic acid gas with good effeas. The prison has been fumiga- ted repeatedly with the nitrous acid gas, after the plan of Dr. Carmichael Smyth; and constant fires of wood were kept in every ward, the strictest attention being paid in all other respeas to cleanliness and ventilation. 39° " The different days of the fever on which the patients died, spfar as could be ascertained, are as follows: 1st day 1 died brought forward 19 3d 2 12th day 5 died 7th 4 13th 14th 2 8th 3 16th 2 9th 5 17th 1 10th 3 18th 4 11th 1 19th to 30th 8 carried forward 19 in all 41 " On referring to Dr. Cullen, the deaths here do not corres- pond with his critical days." On this narrative I will offer a few refleaions. Though the fuccefs of Dr. Jeffcot in. this epidemic is not equal to what occurred in fome other epidemics where the cold affufion was employed, yet if all the circumftances of the cafe be confidered, it will be found very confiderable, and probably unparalleled, in the cafe of any epidemic fever among the fame defcription of patients. Where fever originates among prifoners of war, it mufi neceffarily attack many perfons of broken and worn-out conftitutions. This was certainly the cafe at Stapleton; as I paffed through the wards of the hofpital, I noted the worft cafes that prefented themfelves. Thefe were men rather advanced in life, and the few whofe hiftory I in- quired into had been debilitated by fervice in the Weft Indies, When a contagious fever originates among prifoners of war, the fubjeas of it are unfavourably fituated in various other refpeas. They have neceffarily been for a confide- rable time before expofed to the pre-difpofing caufes, all of a debilitating nature. Thefe caufes may be eafily enumerated; a flender diet—depreffion of fpirits—bad and filthy clothing—-foul air, from being too much crouded together—and a great want of perfon al cleanlinefs. It is to be obferved that prifoners of war are fometimes too much crouded together, not from want of fufficient fpace within the walls of the prifon, but from want of a fufficient fupply of fuel and clothing to protea them againft the 391 inclemency of the weather. Hence they voluntarily col- lea together in a very inadequate fpace, that they may profit by the warmth of the air of refpiration, without be- ing aware that the fame procefs that warms it contaminates it alfo. The houfe for the reception of prifoners of war in Liverpool was a noble prifon, built by the Corporation of that town, for the purpofes of folitary confinement after the plan of Mr. Howard. When I vifited that prifon in the winter of 1800-1801, I obferved that in a cell deftined for a fingle prifoner, there were often eight or nine French- men crouded together, which was twice as many as was requifite, fuppofing the whole to have been diftributed equally. On inquiring into the caufe of this, I was told that they were not allowed fuel, except in the cooking kitchens; that they were without fufficient clothing, and that they had crouded together in this manner to keep each other warm. It is perhaps in part owing to circum- ftances of this nature, that epidemics ufually break out among prifoners of war in the inclement feafon. How far circumftances of this kind might occur at Stapleton I do not know, but undoubtedly the prifoners there had been expofed to the general caufes which pro- duce infeaious or jail fever. Thefe operating for a time infenfibly, gradually enfeeble the conftitution, and impair its power of contending with the difeafe to which they at laft give birth. I have mentioned that the arrangements of the prifon hofpital at Stapleton feemed good; that the food, attend- ance, and medicine, feemed under the circumftances of the cafe liberal and ample. Yet it cannot be fuppofed that where an epidemic proceeded fo rapidly and extended fo widely, fuch arrangements could have been made before hand in a common prifon, where the hofpital was fitted up for the occafion, as in an eftablifhed hofpital for the reception of fever; and of this, 1 could offer from my own obfervation feveral proofs. With all thefe difadvan- tages, the fuccefs attending the mode of. treatment at Stapleton, will bear a comparifon with the fuccefs of the ufual praaice in fimilar epidemics, where the collateral 392 advantages have been greateft, and the fuccefs moft dif- tinguifhed. And if the fuccefs in the laft epidemic fever at Stapleton be compared with what has occurred in former epidemics, fimilarly circumftanced, it will I apprehend appear ftill more ftriking. In this very prifon at Stapleton, and in feveral others, great mortality prevailed among the fame defcription of perfons in 1800 and 1801, in part from contagious fever. The details are not known to the public, but are no doubt recorded by the Board of Sick and Hurt. In all the prifons of war throughout Europe indeed, epidemics of this nature occur too familiarly. But the records of all thefe it is feared might be fearched in vain, before another inftance could be found of eight hundred and fifteen prifoners be- ing feized with jail fever, and only forty-one falling vic- tims to the difeafe. That a remedy fhould have been ufed by which in nearly one-half of thefe cafes, the progrefs of the fever fhould have been arrefted in the firft ftages, is a circumftance I appre- hend not merely without parallel, but without fimilitude in the annals of difeafe among prifoners of war. On reviewing the hiftory of the epidemic fever at Sta- pleton, it may be obferved that the contagion was extin- guilhed with confiderable difficulty. From the day the fever was firft obferved, till the appearance of the laft cafe in the hofpital, a fpace of time which I denote the conta- gious period, three months and ten days elapfed. This may be explained. It was in the ordinary fleeping place of the prifoners, that the febrile virus had its origin. It arofe no doubt, from the contamination of the atmofphere, oc- cafioned by too condenfed a refpiration and perfpiration. When contagion originates from this caufe, and in this gradual way, it is difficult to eradicate it from the fpot of its birth, becaufe the walls and timbers of the building have become by degrees tainted with it, and retain it long after the healthy degree of ventilation has been reftored, and after the moveable articles have been purified by ablu- tion, or expofure to the wind. This difficulty often oc- curs in the medical hiftory of the navy, when particular 393 fhips have been contaminated in this way. Thefe frequent- ly retain the contagious taint for a long while, in fpite of every exertion to fubdue it* The contagion at Stapleton would no doubt have been more eafily and fpeedily fubdued, had it been poffible to have removed the prifoners into other quarters4 or to have en- camped them in the fields. The firft it Was impofliblero find; and the other expedient could not have been reforted to at that inclement feafon, even if camp equipage had been at hand, from the general debility and defeaive clothing of the prifoners, many of whom were affeaed by pulmonary com- plaints. Thefe circumftances oppofed a propofal that I made, of having all the prifoners ftill free from contagion bathed in cold water daily, as a means of cleanlinefs, and a meafure of prevention. Had the epidemic occured in a more fouthern climate, or in a mild feafon of the year, much benefit might have been derived from the encamp- ment of the uninfeaed, and their daily ufe of the cold bath, as was praaifed in the 30th regiment.—(See vol. i. chap. iii). The benefit derivable from the cold bath as a preven- tive, was ftrikingly illuftrated in an epidemic fever which lately prevailed in the Horfe Guards, (the Blues), at Can- terbury, of which, on this and other accounts, I infert a few particulars, as furnifhed me by Mr. M'Gregor, lately fuperinrendant furgeon of the Indian army in F.gypt, and now furgeon of that regiment. I quote from Mr. MfGre- gor's letter to me, dated Windfbr, 30th December, 1804. " A short account of the regiment previous to the breaking out of the fever will be necessary; as it will be seen that the modifi- cation of typhus which took place was peculiar. "The Blues went to Canterbury in Oaober, 3803, in the healthy state which this old corps generally enjoys. In the months of November, December, and January following, a good many cases of fever had appeared, and several died of it; and I have been informed by my very intelligent assistant, Mr. Peach, that it was from that combination of typhus and pneumonia, which has been SO 394 denominated pneumonia typhoides. I joined the regiment, ii the" beginning of March, there were then few of the men sick, though in April, May, and June, the number was thought con- siderable for this corps. These were chiefly cases of pneumonfy of slight fever, or au intermixture of the two. " In July, I first remarked a general appearance of unhealthi- ness in the regiment, though the total on the sick list only amount- ed to twenty-eight; yet on the parade it was observed that the men had not a healthy look. Several foul ulcers appeared among them all at once, and any kick or trifling sore speedily degene- rated into a foul spreading ulcer; and in several cases extensive mortification took place." Mr. M'Gregor goes on to state that he was first alarmed with the appearance of contagious fever on the 28th July. A patient was brought to the hospital covered with petechia?, and died on the 30th. His situation forbade the cold affusion. On examining the barracks at this time, Mr. M'Gregor found them " extremely crouded and uncomfortable." On the 11th of August, another formidable case of typhus appeared; the patient died on the 14th. Great debility joined to diarrhoea for- bade the cold affusion here also. Six other cases speedily follow- ed. (t In September,'3 says Mr. M'Gregor, " our situation became Alarming in the extreme, nearly a fifth of the regiment were on the sick list. In particular there were thirty-three cases of fever, and six of dysentery. On application being made to Sir David Dundas, he ordered the regiment to be encamped, and this was done on the 5th. After this, however, we continued to deteft a number of cases of the fever, and the hospital was found too small for the sick. About the 12th, at my earnest recommenda- tion, all the regiment out of hospital were marched three times a day to the river side, and every man was made to bathe. The good effeas of this were speedy and manifest, the number of new fever cases decreased daily, and those that did appear wore a milder aspea. Many indeed yielded to the common treatment; in some cases an emetic, and in others the cold bath, at once cut short the disease. We lost no case in Oaober. Indeed it was evident to all, that after the general bathing of the regiment, the contagion stopped; the few cases that occurred after this, were stripped of all the alarming and dangerous symptoms with which the disease broke out. In all, there were sixty cases of fever oc- curred from July to the 21st of Oaober, on which day the last case appeared. We lost six of this number." Of thefe fatal cafes he details the particulars of three. *Two have been mentioned:—-in the/e the cold affufion wa9 395 not ufed as a remedy. In the third it was ufed repeatedly and perfeveringly; and always with apparent benefit: bu$ the cafe was complicated with diarrhoea, and the patient funk at laft of mere debility, on the 23d day after admiffion into the hofpital. Of the three other fatal cafes there are no particulars, " We were successful with the cold affusion," says Mr. M'Gre- gor, " but it was in such cases as you recommend, and by follow- ing your method closely. It did not, however, in general, suc- ceed in cutting short the fever. In one case only did it appear to be followed by bad consequences. In this case dyspnoea and great coldness followed immediately, and afterwards a great determina- tion to the head. The tepid affusion was then applied with suc- cess, and though the disease was tedious, the patient recovered. In most cases which occurred, especially where there was a de- termination to the lungs or intestines, the tepid bath or affusion did the most signal service, and was not unfrequently called for by the men themselves. « Towards the end of September many cases of dysentery ap«- peared in the regiment; it soon became epidemic in Canterbury, and proved a most severe and fatal disease to the troops and the inhabitants. « I have mentioned in another place,* that in some suspeaed corps, the cold bath appeared to have prevented the breaking out of the plague, and to have destroyed the pestilential contagion. I am happy now to find that I have beeft putting to the test of experiment in Egypt, opinions given out by a learned physician of this country, Dr. Falconer, of Bath.f I am no less happy that experience in the typhus at Canterbury, supports the conjec- tures of our venerable friend, Dr. Wright, « that cold bathing will prevent fever," &c. See page 378 of this volume. " I wish I could say as much of its preventive power respeaing the dysentery of Europe ; but from my very limited experience on this point, i will not venture to speak; though the state of the Blues at Canterbury is in favour of such an opinion, only twenty cases of dysentery having occurred after the cold bathing was generally adopted." The hiftory of this epidemic fuggefts a variety of re- fleaions. The Blues marched into Canterbury in good * Medical Sketches of the Expedition to Egypt from India, by Jame, M«Cregoi, ^,M. Murray, London, 1804. f Effay on the Plague by Win. Falconer, M. D.. F. R. S. B.th. i?aiv 396 health. There thev gradually became unhealthy; while the other troops and the inhabitants of the city enjoyed their ufual health. It is at Canterbury the caufe of the unhealthinefs of the Blues is to be looked for, and it muft have been one to which they Were peculiarly expofed, fince they alone were for fome tirne affeaed. Qn confidering every thing, this caufe may reafonably be traced to the crouded and uncom- fortable ftate of their barracks; to the gradual operation of foul air, arifing from this circumftance, the predifpofition to difeafe is more immediately to be imputed, and finally the contagious fever itfelf. The injury to the air of refpiration from a caufe like this may be various. T/here is no doubt that it may be in that degree which, continued from day to day, gradually faps the vigour, without for a confiderable time producing thofe fymptoms which conftitute abfolute difeafe. Illuf- trations of this may be found in W\r. M'Gregor's narra- tive. In July the Blues had an unhealthy look on parade, Sind accidental wounds among them degenerated into foul ulcers. The fever was then impending which in Auguft burft out. There is no doubt that a fever originating in this way would affume appearances of malignity from the firft.— \Ve fhould naturally expea what really occurred,r—great proftration of ftrength, feeble re-aaion, early fymptoms of putrefcence in the fluids, and that tendency to affeaions of the bowels, with which fuch fymptoms are fo generally combined. Cafes fuch as thefe are lefs favourable than moft others for the cold affufion, which, however, where it had a fair chance, feems to have produced in this fever its ufual good effeas. But as a preventive its influence was indeed very ftriking, and deferves the particular at- tention of military praaitioners. This leads to, a fubjea, which it would be improper to pa/sqyeri and on which it would be painful to dwell— 397 the late fatal epidemic fever at Gibraltar. The following particulars refpeaing it are derived from fources of infor- mation on which reliance may be placed. After a fummer, faid to have been unufually warm, and a long prevalence of eaft-winds, during which the town of Gibraltar, which is fituated on the weft of the rock, was in a great meafure becalmed, a malignant fever made its appearance among the inhabitants and troops. It was firft obferved about the 10th of September, 1804; it fpread with fatal rapidity, and continued its ravages with more or lefs violence till the month of January following; on the 12th day of which it appears by a certificate from the Board of Health to the Lieutenant Governor, that the dif- eafe was extinguilhed. During this period out of about »8,000 inhabitants, military and civil, 12,000 were affea- ed by the fever, and of thefe about 6000 died. Unhappily many moft important points refpeaing this uncommonly fatal difeafe, are differently reprefented by perfons on the fpot fecmingly of equal authority—thefe refpea its origin, its nature, and its proper treatment. On the firft appearance of this epidemic, the prevailing opinion among the gentlemen of the faculty at Gibraltar, was, that it did not originate in infeaion or fpread by in- feaion, but that it was to be imputed to the exrreme heat, or fome other general quality of the atmofphere.* Means of prevention founded on the belief of its infeaious na- ture, were in confequence not reforted to for fome time; not indeed till it had fpread univerfally. Thofe who main- tained the non-contagious nature of the difeafe, confidered it as highly inflammatory, and reforted to blood-letting and other remedies fuited to this idea. By others it is contended that the fever had its origin.in imported contagion; that it was no other than the fever which made its appearance at Cadiz, in Auguft, 1800, and fpread to Malaga, Seville, Xeres, and the furrounding country, where it was faid to have carried off 100,000 %4 • At one time it was imputed to the effluvia of a burning lime-kiln; which was in confequence extinguished. 39« perfons. The contagion feemed never fince that time t% have been wholly extina. The fever is faid to have re- appeared w:th great violence at Malaga, in Auguft, 1803, when the Spanifh government, to prevent its fpreading, eftablifhed a corcdon of troops round the town, which on this occafion is fuppofed to have loft 17,000 fouls. In Auguft, 1804, it appeared again at Malaga, a month previous to the epidemic's breaking out at Gibraltar. The inhabitants of Malaga fled on this occafion on the firft alarm, (probably to avoid being confined by a cordon of troops as before), to all the towns along the coaft from Cadiz to Carthagena, carrying the difeafe along with them; and hence the fever, which was more general this year than at any former period, is fuppofed to have found its way into Gibraltar. This reprefentation is ftrengthened by the following cir- cumftance. In former years when the fever prevailed at Malaga and elfewhere, meafures of precaution were adopt- ed at Gibraltar to prevent its introduaion there; particu- larly that of a quarantine on all veffels from Spain, while veffels from the ports where fever was fuppofed to prevail were not allowed even to anchor. Health-guards were efta- blifhed at all the landing-places, and guard-boats were ftationed in different parts of the bay. The medical prac- titioners, the catholic priefts, and the heads of the Jews, were direaed to report every fufpicious cafe of fever efpe- cially among fmugglers and other ftrangers, who might clandeftinely gain admiffion into the garrifon; and in fome inftances fuch cafes wtre removed to the lazaretto with the perfons who had harboured them ; and the houfes in which they had been found were burnt to the ground. Thefe meafures, which in former years had apparently proved fo falutary, had been wholly negleaed in 1804, and when the fatal epidemic aaually appeared in Gibraltar, it was rafhly concluded that it had not been received by infection, and was not in its nature infeaious, fo that meafures for preventing its fpreading were for a confiderable time wholly negleaed. When they were had reeourfe to, being adapted in the midft of terror, confufion and death, they were"Imperfea, va~ 'able, and unfuccefsful.— 399 We now know that the fever was contagious*; evidence has accumulated on that point to convince the moft fcepti- cal. And this being admitted, the preceding account of its origin is confiftent and probable. Having examined feveral reported cafes of this fever and the accounts of fome difteaions, the following feems to me a general fummary of the fymptoms. After fome ge- neral uneafinefs and fenfe of cold, the patient is feized with head-ache or vertigo, pain in the back and limbs, and great fenfe of langour and debility. The pulfe is fre- quent but not ftrong; the fkin dry; the tongue lightly furred; the thirft and heat preternaturally great, but not violent. Thefe fymptoms increafe; naufea comes on, and vomiting often enfues. Debility augments rapidly, and the ftomach becomes more and more irritable. Dullnefs, ftupor and low delirium come on; the body is covered with petechiae. With an almoft conftant difpofition to naufea and vomiting, there is alfo a tendency to purging.—The fenfibility decays more and more—the parient utters no complaint—the abdomen fwells—blood is difcharged in the ftools, and fometimes from the noftrils.—The pulfe finks j the extremities become cold ; and the patient ex- pires quietly. On opening the ftomach and bowels, they are found in a ftate of commencing mortification. In the courfe of the difeafe, many complained of great anxiety and oppreffion about the prfccordia, with a fmall and fluttering pulfe. Many had the black vomit, and fome had a retention of urine, or rather a deficiency in the uri- nary fecretion. T hefe were very unfavourable fymptoms. In many cafes mortifications of the extremities took place —in fome few, anthrax and parotis. The difeafe ran its courfe rapidly—many expired on the 4th and 5th day, and fome earlier. Thefe are the ufual fymptoms of peftilential fever.— They differ little from thofe of the plague, except in the abfence of bubo, to which however there appears to have • I ufe the words contagious and infeaious, as fynonimous. The Anglo- American diftinaions in the ufe of thefe terms, will only be adopted by thofe who adopt the dangerous doftrines which gave rife to them. 4oo been a tendency. It is to be lamented that we have no ac- curate account of the heat in this difeafe, the thermometer not having been applied, fo far as is known, in a fingle inftance. From the accounts of the treatment which I have feen, it was ufual with thofe who did not conceive the difeafe to be inflammatory, to adminifter emetics in the firft inftance; afterwards gentle purgatives—falines—opiates—mineral acids—and wine in moderate quantities :—^occafionally alfo aether and other cordials. Blifters were commonly applied. Bark does not feem to have been generally ad- miniftered, the ftate of the ftomach fcarcely admitting it. On the whole the method of treatment, however different in the hands of different praaitioners, feems to have been very unfuccefsful. Of all that were feized with the fever, one half are faid to have periflied, a proportion greater, I believe, than is ftated in the well-authenticated hiftory of any modern epidemic fever, and nearly equal to what has occurred in the plague itfelf.* Neither were the means of prevention, too tardily adopt- ed, to appearance more efficacious.—The epidemic raged four months. It leffened in December, and died away in January, but whether in confequence of meafures of pre- vention, of the progrefs of the cold weather, or of other caufes, does not appear. The fever of Malaga ufually dif- appeared in December. Thofe fpecific contagions of which the conftitution is indefinitely fufceprible, feldom make two attacks in imme- diate fucceffion. Were it otherwife their ravages would know no bounds. Hence it happens that after a time, they naturally ftop for want of viaims. At Gibraltar two thirds of the whole population were affeaed by the fever before it ceafed, as great a proportion probably as has been feized at any time by an epidemic fever. It has been faid that fuch of the officers and foldiers as * On a comparifon of the accounts of different authors, Dr. Falconer found the deaths in the plague to be to the recoveries nearly in the proportion of 10 to 9.—ElTay on the plague, by W. Falconer, M. D. F. R. S. p. 13. 401 had before been affeaed by the yellow fever of the Weft Indies, efcaped the fever of Gibraltar. Such affVrtions cannot be admitted without ftrong evidence. The yellow fever of the Weft Indies, if we may credit the moft re- fpeaable teftimony, has often affeaed the fame perfon twice ; and from the lateft and moft indifputable accounts, the plague, to which the fever of Gibraltar, bore fomuch refemblance, though feldom repeating its attacks without fome interval of time, may however be received by the fame perfon indefinitely. The reader will naturally expea to hear fome account of the effeas of the cold bath, or cold affufion in the epidemic of Gibraltar, as a remedy and a prophyhaic. Confidering that this epidemic held its fatal career for four months and upwards, and that all the ufual modes of treatment failed, it might naturally have been expeaed, that thofe in attend- ance on the fick and dying, would in thefe defperate cir- cumftances have had reeourfe to a mode of praaice, which in fimilar fituations had been attended with uncommon fuccefs. The firft volume of the Medical Reports, had been feven years before the public, and had paffed through three editions in our own language. The fecond. volume had alfo appeared, and had met general attention. The work had been favourably received on the Continent, and began to influence the military and naval praaice of foreign nations. Of this a remarkable proof had appeared in the fecond volume, in the narrative of the phyfician Dr. B. A. Gomez, who in the fummer of 1802, when a fatal fever prevailed on board the Portuguefe fleet, had reeourfe to the cold affufion after every other remedy had failed with a fuccefs altogether extraordinary. This was the more ftri- king as the Yever fofar as we can judge, feems to have been the fame that committed fo much devaftation in various parts of the Spanifh peninfula, and that at length intruded into Gibraltar itfelf:—the more ftriking alfo as the fever in the Portuguefe fleet occurred in the ftraits of Gibraltar, in fight of the garrifon, and the extraordinary fuccefs of Dr. Gomez, even had it not been publifhed to the world, might have tranfpired to the praaitioners on fhore. It is a duty, 51 402 however, that 1 owe to the public to declare, that the fa- tality of the fever at Gibraltar, brings no imputation on the mode of treatment recommended in thefe volumes, for after the moft diligent inquiry, I cannot find that the cold bath in any form was ufed either as a prophylaaic or a remedy in any fingle cafe of the difeafe. Neither can I find that tepid ablution or affufion, was in any cafe reforted to, or that water was recommended as a drink. I record thefe faas with feelings very different from thofe of wounded vanity—if they bear hard on the feelings of any other per- fon, 1 regret the circumftance.—But this is a cafe in which my fenfe of duty obliges me to fpeak out. I will however make no comment, but leave the fubjea to the reader's refleaions I* * In a letter to Mr. M'Gregor from Mr. Bennion, garrifon furgeon of Gibraltar, a copy of which has been communicated to me by the kindness of Dr. Butty fince the above was written, I have found a very clear and I dare fay a very exa£l defcription of the fever, which as it is to appear in the Me- dical and Phyfical Journal for Auguft, I decline to infert here. It agrees in fubfVance with the account I have given, and fhews the good effe&s of the warm ablution. " At firft," fays Mr. Bennion, •* it appeared to be the opinion of the " majority, (of the medical men in the ganifou), that the difeafe was not " contagious, a fatal op nion to be acted on, as fubfequenily appeared. I *• arrived here a few days after the difeafe made its appearance, and of courfe " could not give an opinion on the point, till I had inquired into its hiftory " and fymptoms. Alas! I foon found it to be the neareft relation to the '« plague, fome cafes from the firft putting on the appearance of that difeafe, " often of the typhus gravior, and others of the yellow fever. " As to the mode of treatment, that which I followed is very fimple and " foon defcribed. I have little to remark on the plans of others: it is known k' however that they were not equally fuccefsful. Some of our ableft men iC were inclined to interrupt the difeafe but little, and gave little but diluents " and cordials. Others bled very freely ; and others gave the bark liberally " and early. " My mode of treatment was as follows. My firft ftep was invariably to " put every patient into a bath which was generally warm. When taken " out the body was well rubbed with foaped flannel, and then he was put to "' bed. If the powers of life were ftrong, an emetic foiution was next gi\en ,e of taitar, antimonial and natron vitriolatum. The folution generally ope- " rated pretty fmartly both on the ftomach and bowels, and when it did its " office well I frequently h. d little more to do but remove debility. The •' patient being often well on the third day. If the folution peifevered in for " fome time did not operate, which was fitquently the cafe at firft, the " ftomach and bowels being very infenfible, I gave calomel, and continued " giving it either by itfelf or with jalap, or with the compound extracl of •' colocynth. I endeavoured by all means to keep up the-alvme difcharge 403 On a review of the fatal epidemic at Gibraltar, there are other circumftances to excite our deep regret. Of this kind is the neglea of the ufual means employed to prevent the introduaion of fever into that garrifon, when the ports of Spain were affeaed by contagious fever. Of this kind alfo was the rafh declaration, when the fever did appear in the garrifon, that it had not originated in contagion and was not in its nature contagious: two propofitions diftina in themfelves, but which have been prefumed without proof to involve each other. However general the contrary opi- nion may be, the fever of Gibraltar, fo far as we know*, might have its origin in fome noxious quality of the gene- ral atmofphere, or in marfh miafmata, and yet be propa- gated in the fecond inftance by infeaion. It is greatly therefore to be lamented that meafures were not taken im- mediately to feparate the fick from the healthy. Thefe ought indeed to be reforted to in every inftance of the ap- pearance of general fever, efpecially as according to the prefent ftate of the evidence, they are equally eafy and effeaual. There is no fafety in confidering a fever to be non-contagious in the firft inftance, and waiting for evi- dence to the contrary. There is neither wifdom nor mercy, in declaring it to be non-contagious while the point is in doubt, with the view of preventing general alarm. To have adopted the meafure's of precaution requifite in the cafe of " when obtained, (till) the patient was found perfectly relieved, and free of " fever. If not, the 4th or 5th day generally put an end to all inquiry. But " in many no evacuation could be procured by any means, in others there was " a violent diarrhcea. " I difTected the bodies of a few. The general appearances were the de- " ftiuctionof the internal coat of the ftomach, " inflammation and ulceration " of the intellines, and fometimes of the (other) abdominal vil'cera. I have " little more to fay than that after procuring evacuation, I puilued falme me- " dicines, when little fever remained, but when the difeafe continued after the " third day, it frequently turned out to be the fevereft typhus. I then found " the greateft benefit by Dr. C. Smyth's method, as laid down in his book " on the Winchefter fever. Opium or bark did not fucceed : when liberally '* given I perceived them doing mifchief." , This account of Mr. Bennion's practice fhews the benefit of early ablution, and early evacuations, which though with a confiderable wafte of ftrength as conducted by him, muft have taken off the febrile heat, and in fome cafes cut fhort the difeafe. I was in hopes from the general accounts I had received, of finding fome particulars of the effects of the cold bath in his practice, but have been difappoinled. 404 an infeaious epidemic, unneceffarily, is a light evil. In a mi- litary garrifon,.where fubordination and difciplme are alrea- dy eftablifhed, it is no evil at all. At the worft, fome trou- ble may have been incurred which might have been fpared. —How melancholy the reverfe of this fuppofition ! What fhall the theorift fay for having trufted for fafety to his fpeculations, where the lives of thoufands were at ftake ? what reparation can he make for his errors, when the proofs that convia him, are the graves of his. countrymen ? To pronounce a difeafe to be contagious, ought not to deprive the fufferers of the aids of fcience or of humanity, as fome weakly fuppofe. It ought now to be generally known that fimple means of precaution, adopted early and fir icily ad- hered to, do away the danger to the attendants, and the praaitioner of medicine that cannot truft his own fafety to thefe, is unworthy of his office, and ought to lay it down. And, let it never be forgotten, that the means of preven- tion to the uninfeaed are means of cure to the fick. To keep off the idle and unneceffary intrufion of thofe in health, is to fecure to the fick filence and quiet;—to enforce univerfal cleanlinefs and ventilation, is to increafe their comfort, and fupport their ftrength ; while the regular and prudent ufe of perfonal ablurion, which of all the means of precaution-is perhaps the moft important to the healthy, is of all the means of cure certainly the moft efficacious to the difeafed. The praaice I have recommended hi fever is becoming general in the navy, of which a variety of proofs have been furnifhed me. It is alio fpreading in the army, and it has attraaed the notice of his Royal Highnefs the Commander in Chief. The official reports of a fever in the Suffex Militia, in barracks at Chelmsford in January laft, have been com- municated to me by the kindnefs of Mr. Knight, Infpeaor General of Hofpitals.' In thefe Mr. Knight and Dr. Ro- berts bear ftrong tcftimonies to the efficacy of the cold affu- 4°5 Con, both as a remedy and a prophylaaic; and the former has earneftly recommended to his Royal Highnefs the Commander in Chief, the equipment of every barrack hofpital with a fhower-bath, the flipper-bath with which fome of them are fupplied, being applicable to warm ba- thing only. .This recommendation has met with due at- tention, and fs now carrying into effea. There is reafon to believe alfo, that our military praaitioners will in future be furnifhed with thermometers, for afcertaining the heat in febrile difeafes, of which we may in future expea more accurate reports. The ftate of my health having obliged me to abandon my laborious duties at Liverpool, I paffed the winter at Clifton, as was before mentioned, and fixed my refidence in Bath in the prefent fpring. Typhus fever, is compara- tively fpeaking of rare occurrence in this city. It has how- ever been my good fortune to prefcribe the cold and tepid affufion in feveral cafes of typhus, and of fcarlatina, in Bath and at Clifton, with its ufual good effeas. There feems no doubt of this method of cure extending here and every where. My tafk then I hope is finifhed ; and with a few words more ftriaiy of a perfonal nature, I fhall lay down my pen. Having had an apparently hazardous, but in my judg- ment a highly falutary medical praaice to recommend to the world,—'a praaice contradiaory to long eftablifhed and almoft univerfal prejudices, I refleaed beforehand with the utmoft ferioufnefs on the duty impofed upon me, to avoid in my manner of prefenting it all poflible grounds of offence. If my matter was alarming, if my objea was bold, I have endeavoured to make my manner calm and temperate. The claims of my contemporaries to merit on this occafion, fo far as I was acquainted with them, I have ftudioufly brought forward. I have been defirous of treat- ing them not merely with juftice but generofity ; and many feries of experiments which I myfelf have undertaken, and I may fay undergone, efpecially in inveftigating the effeas of perfpiration on animal heat, I have fuppreffed in the detail, and only given in the refult. in a word, it ha5 406 been my endeavour to fupprefs all perfonal confiderations, and all petulant expreffions ; where I could employ the au- thority of others, to do it freely and refpecifully ; and where I have been led by my fubjea to controvert opinions before the world, to ufe the language of civility and can- dour. s By thefe means I have endeavoured to dilarm perfonal oppofition, and to avoid controverfy—controverfy which fome philofophers have invoked, but I think unwifely; and which on a fcience fo imperfea, fo important and fo difficult as that of medicine, feems to me to have almoft uniformly involved confequences of an injurious and me- lancholy nature. On the whole my endeavours have been fuccefsful. I have encountered little oppofition -, I know not that I have provoked any man's enmity; while the medical writings of the day, both in Britain and in America, bear evidence that confiderable changes have been effeaed and are effea- ing on the opinions' and condua of medical men, quietly and infenfibly, on points of no mean importance, in phy- fiology, as well as praaice. J. c Bath, 6th July, 1805. &ppentn% PREFACE TO THE LETTER TO DR. CLARK. A CONTROVERSY having arifen among the gen- tlemen of the faculty at Newcaftle, as to the fafety of admitting patients under fever into certain wards of the Infirmary there, feparated in every other refpea from the reft of the hofpital, but under the fame roof, my friend, Dr. Clark, appealed to the opinions of his medical friends and correfpondents, in different parts of the kingdom, and colleaed a body of evidence in fupport of the meafure, which feems altogether decifive. The whole colleaion* contains perhaps the cleareft and moft fatisfaaory informa- tion on the queftion refpeaing contagion, that is any where on record. The following letter forms a part of that col- leaion ; as it contains fome curious faas on this important fubjea, it is inferted here. No. I, LETTER TO DR. CLARK. Dear Sir, Liverpool, August 5, 1802, TO the great mass of evidence and authorities which is already* adduced in favour of the plan of receiving fevers into the new building attached to your Infirmary, I can scarcely con- sider any addition as necessary; but as the experience derived from our fever-wards here is now of fifteen years duration, and as it may bear more or less on the important question at present * Publiftud under the following title, " A colleaion of papers, intended to " promote an inftitution for the cute and prevention of infectious fevers in " Newcaftle, and other populous towns. Together with the communica- " ttons of the moft eminent phyficians, relative to the fafety and importance •« of annexing Fever-Waids to the Newcaftle and other Infirmaries. By John " Clark, M. D." Two vols, izmo, Neivcaftle, printed hy S. Hodgfon, i8oz. 408 agitated with you, I am happy to comply with your desire, in gi- ving you a more full account of it. In the report of your committee is republished an extraa of a letter of mine to Dr. Percival, dated May, 1796. I there men- tion, that for five years and a half, we had received patients in fever into the Liverpool Infirmary, and for the greater part of the time, into two small wards, on the ground floor of the left wing. These patients were on the general establishment of the charity, and had their food and medicines provided in common with the other patients. They entered into the yard of the wing by the same large folding doors which admit all the other patients; but the fever cases were afterwards conveyed into these two wards direaiy, without using the common stair-case of the wing. Im- mediately over them, however, were the wards of the other pa- tients, and it was impossible to seclude the nurses of the fever- wards entirely from the other servants of the house; yet, in no single instance was the contagion extended to the contiguous wards. I have also mentioned, that at the end of five years and a half, the place for the reception of fever was removed from those small and ill-construaed wards, to two large and airy wards in the centre of the work-house, a description of which is given. Four years had then elapsed from the commencement of that ar- rangement, during which time there was no reason to believe that the contagipn had, in any instance, spread from the fever wards to the rest of the building. Six years more have since elapsed, and on the striaest inquiry, I find, that the same asser- tion may be made up to the present day. In order to point out the nature and value of this experience, 1 must be more precise and minute than is agreeable, and must even repeat some particulars in my former letter. Our work-house is a very large building, which sometimes has contained one thousand four hundred persons, and which is in many respeas very imperfeaiy construaed. The great door in the centre of the building opens immediately into the great dining- room, but is never used. All the persons who enter the house, sick or well, pass through a small door in the right wing, seven feet high, by about three feet and a half in width, where a por- ter constantly stands to prevent the exit or entrance of the inha- bitants, excepting under the rules of the house. The sick are re- ceived at this door, whether labouring under fever or not, and are carried across a passage to a receiving house, of which there is one for each sex. Here they are stripped and washed, and their clothes changed ; the apothecary examines them on his daily visit, and sends those under fever to the fever-wards. The access to 4°9 these wards, is, as I formerly mentioned, through the common stair-case of the centre of the building. On the ground floor is the great dining-room, the access to which, from the rear, is through the area at the foot of this stair-case. On the next floor, is the lock-hospital for females; on the third floor, the fever-wards; and on the fourth, the children's nursery. For the ten years in which the wards have remained in this si- tuation, there has been no contagious fever in the lock hospital. But two years ago, a very alarming fever broke out in the nurse- ry, and extended to no less than sixty-seven children, all of whom recovered by the early application of the usual remedies, of which early and frequent ablutions formed the principal part. This might be supposed to have originated from the fever-wards below —but, on inquiry, it was clearly traced to another source, as you will see by the letter from Dr. Bostock, the attending physician. at the time, a man of great accuracy.* Except in this instance, contagious fever has been unknown in the nursery, where the apartments are clean, spacious, and well-ventilated, being at the top of the building, and the children have the appearance of health and vivacity. Whatever your sentiments may be respeaing the narrowness of the sphere of contagion, I think you would not have ventured to predia such a singular exemption from (exer, under such circum- stances For the children are continually passing up and down the stairs, and playing in the stair-case ; and, at particular times of the day, that is, immediately before dinner, they are crouded towards the bottom in a singular manner. The faa is, their food is distributed to them from the dining room, where a great body of the people from the wings of the house dine; and as the doors open at a certain hour, a great croud coUeas previously at the bottom of the stair-case, and in the area below, struggling for ad- mission. . While I was examining this ill-construaed stair-case, which is never clean or sweet, about two years ago, a patient un- der fever, was brought across the court, a little previous to the dining hour. I followed the patient up into the ward, and count- ed exaaiy eighty-three children on the stairs, within three or four feet of every one of which, the patient must have passed, and to • About two years ago, a ve«-y alarming fever broke out in the nurfery, by which no lefs than fmy-leven children were infefted. The lou.ee of this difeafe w. sr how- ever, dearlv dilcovcred ; a family, refiding in a cellar in one of the molt confined parts or the town, was fent in a ftate of fever to the work-houfe 5 the parents wcrr placed^1 the wards, but by fome neglect, the chil !ren were l-nt into th- nurler., withi.rne de- grec of the diieafc upon them, an J without removing the infected clothes wh cn thjy had worn beftre they came into the houfe. . Extract of a letter from Dr. Iioftock, to Dr. Curnc, printed in vol. i. p. 199, (f Or. Clark's Cdieffm. 52 4io some much nearer. On mentioning the circumstance to the nur- ses, they seemed to think it nothing uncommon, but as what might happen any day. Though no clear instance of injury arising from such occurrences can be brought, I have always deprecated the circumstance which leads to them, and in conjunaion with others of my brethren, urged, in the parish committee, the propriety of having a distina passage to and from the fever-wards. Various consultations were held on this point, but the strufture of the building rendering such an alteration impossible, without entirely defacing the front, the want of any aaual proof, or even appear- ance of injury from using the common stair-case, cooled our zeal. The probability of a separate house for fever, from the inade- quacy of the present wards, rendered it less necessary to press the alteration, and the proposal is at length happily superseded, by the aaual ereaion of such a house, now in rapid progress. The fever-wards themselves, though very far from being suffi- ciently extensive, are admirably ventilated, and, on the whole, very'happily conduaed. The nurses still live in these wards, night and day, their apartment being in the centre between them, and open at the top to the air of both, as described in my letter to Dr. Percival, already referred to. In the course of ten years, se- veral of them have caught the contagion, but assistance being im- mediately had, one only has died, so far as I can learn, a woman upwards of sixty, and otherwise very infirm.—In the instances where the contagion has been thus communicated, it has been to nurses newly introduced. They have seldom been, any of them, affeaed more than once; their constitutions acquiring by habit, insensibility to the contagious impressions. I mentioned to you, that two of the present nurses have each of them a child aftually living with them in the wards, and going out to school in the day. These children appear neat, clean and healthy, though they sleep in the very centre of the patients every night. Their mothers were convinced that they were not liable to any injury, for they never came into contaa with the.patients, and they seemed to think they should be themselves perfeaiy safe, if it were not that they are employed in offices that oblige them to be often, and sometimes for a considerable time together, in contaa with the sick, and ex- posed to the undiluted exhalations from their skin, and their lungs. Experience has, however, taught them to estimate even this hazard very lightly; and it is, in faa, as easy to get a nurse for the fever-wards, as a servant for any other part of the house. This exemption of the nurses from contagion, (a few instances excepted), is to be attributed not merely to the ventilation of the wards, but to the singular cleanliness of the patients, on every one of whom, in whatsoever stage of the disease, complete ablution 4ii is performed in one form or other, at least once every day ; thb being done where the fever is high, and the heat considerable, with water perfeaiy cold; and where the strength and heat are reduced; with water tepid, or even warm, and sometimes mixed with vinegar or sea salt. The methods of Morveau or Carmichael Smyth, have never been praaised in these wards, or in the for- mer wards of the Infirmary; and our experience seems to decide, that the proper use of pure water and pure air, may wholly su- persede them. To the praaice of completely washing and changing the pati- ents in the receiving houses, before they are carried up the great stair-case, I attribute the extraordinary circumstance of the con- tagion never appearing to be communicated to the bye-standers in this narrow-passage, of which a melancholy and striking circum- stance has impressed conviaion on my mind. Notwithstanding the healthfulness, and especially the exemption from fever, of all the places in the immediate vicinity of the fever-wards, in the year 1801, the master and mistress of the house, and a young woman, daughter of the assistant mistress, were at different times affeaed with typhus, and all of them died. This circumstance occasioned great agitation. The master of the house had never been in the fever-wards, the mistress very seldom; and they lived in a part of the building very remote. But Miss Nickson, the young wo- man alluded to, had, it was found on inquiry, been incautiously turning over the linen from the fever-wards before it had been steeped in wtter, and to this circumstance her fever was imputed. In all these cases, (one of which only I attended), the disease proceeded insidiously, and was scarcely suspeaed till it was too late. But how, you will ask, does the ca6e of the master and mistress apply to the opinion I have given on the benefit of ablu- tion in preventing contagion ? I have before mentioned, that all persons, sick or well, and the patients under fever among others, enter the work-house by a small gate in the right wing. This gate is close by the apartments of the master and mistress, 'that they may have this important pass immediately under their eye. In faa, the window of their parlour is on the outside of the gate, and within the distance of four feet, and the door of a coach, bringing up a patient under fever, must, from the narrowness of the passage, be within a foot or two of this window. Here the patient is taken out and carried through the door, and generally examined by the master or mistress in the inside. In the year 1801, in this great town, there were admitted on the bouks ot the Dispensary, nearly 6000 patients beyond the usual number; from 12,000, they increased to 18,000, and typhus fever was ex- tremely prevalent. Of course the distress of the poor was great; 412 there was an unusual pressure for admittance into the fever wards-, which were filled beyond all former precedent, and many were obliged to be sent away. The examination of these unhappy per- sons in their unclean and contagious state, unwashed and unven- tilated, and the rejeaion of them when necessary, devolved on the master and mistress, attentive and humane persons, who doubtless fell viaims to this dangerous and painful duty. This is the opinion of their successors, Mr. and Mrs. Hall, who assure me, that they make a point of never approaching within a yard or two of suspeaed fevers, and have hitherto escaped. The por- ter, who has opened and shut this gate for several years, has esca- ped also. He assures me, that he has used the same precaution •> but he inclines to ascribe much of his safety to the use of tobacco, of which he chews very large quantities. The persons employed in washing and cleansing the clothes of the patients, in the re- ceiving houses, have sometimes been affeaed by fever; but being on their guard, and applying for assistance in time, fatal conse- quences have, I believe, never ensued. The striking advantages of external ablution, both as a pre- ventive and a remedy, have engaged our particular attention in the construaion of our new fever hospital. Before the patients enter into the body of the building, they pass by an entrance peculiar to themselves, into a vestibule, where there are baths of every kind, where they are stripped of their foul clothing, washed, and clothed in the hospital dress, and thus purified and refreshed, re- moved into their proper apartments. In the plan which you had the goodness to shew me, I believe there is a provision of the same nature; and if not, I would submit the propriety of super- adding something of the kind, not for the safety of the patients in the adjacent wards of the Infimary, but for the benefit of the fever patients themselves, and their immediate attendants. For as to any danger to the patients of the Infirmary, from the mere proximity of the walls of the fever-house, while you enter by the distina passages, and observe the usual and obvious precautions, the details which I have given you will shew you, that it is impossible for me to listen to it for a moment, even if the uniform experience of the Physicians of Liverpool were not supported by that of every other part of the island, where it can fairly be colleaed. Nothing, in- deed, seems to be more firmly established, than the narrow sphere of even the most virulent contagions, where the air is allowed to circulate freely. Hence, in the torrid zone, where the heat of the atmosphere in a manner forces ventilation, the infeaious qua- lity of the most malignant fevers is a matter of dispute among the faculty, though I believe with yourself and Dr. Wright, (the pre- vent worthy President of the College of Physicians at Edinburgh)» 4*3 that, under a similar deficiency of ventilation, they would be equally, or more infeaious, than the fevers of our northern lati- tude. Dangers that cannot be calculated, are always magnified by the imagination ; and the baleful influence derived to the atmos- phere, from taking its constant course over extensive swamps of many thousand acres of putrifying animal and vegetable matter, has been loosely applied to the same air, passing over a human body, for a thousandth part of the time, and a millionth part of the surface. Yet the testimony of all aaual observers, in every region of the earth, is calculated to correa this error. Even the sphere of the contagion of the plague, the most terrible of the diseases which affea the human species, seems limited to a very few feet, or even inches, in a free circulation of the air ; and it might be received into your projeaed fever-ward with safety to the patients of the Infirmary, if we may believe the concurrent testimony of Savary, Bruce, Russel, and of Antes, the most re- cent and satisfaaory of them all. It is folly to pretend that this subjea is of a professional nature, and not cognizable by any fair understanding. The faas are nu- merous—the inference easy. It is only necessary for unprejudiced men to make themselves masters of the first; the last seems to me inevitable. Even those who will not take the trouble of obtaining the information necessary to inform their own judgments, might regulate their condua safely, by conforming to the usual maxim on similar occasions—that of adhering to the opinion of those who are likely to be best informed. That persons, the business of whose lives is to observe and to combat the effeas of contagion, should be best acquainted with its laws, and their evidence best entitled to weight, in a question depending on those laws, are propositions that no one will dispute; and the force of which can only be eluded by shewing that, in the point at issue, they have an interest likely to pervert their judgment or their evidence. But what peculiar interest have the faculty in institutions for the prevention of disease, unless, indeed, the honourable reputation they may derive from serving the community ? What interest have members of the faculty, already in the possession of public confidence, in committing their reputation to hazard, in the sup- port of plans of a dangerous nature ? If such plans are carried into effea, their effeas cannot be concealed; and if they turn out to be such as their opposers prophecy, they must destroy the re- putation of their supporters. In one point of view it is perhaps fortunate for the world that the controversy at Newcastle proceeds to such a length. The subjea will undergo a complete investigation, and the combat you are maintaining will in the end, I have little doubt, decide the 4H question, not for Northumberland only, but for every part of the kingdom where it still remains undecided. That much inter- est will attach to your proceedings, not at the present moment merely, but in future times, I entertain little doubt. In this, and in every view of the subjea, I have great pleasure in ranging my- self on your side, and in staking, with confidence, what little charaaer I have upon the issue. With every sentiment of respea and regard, I am, Dear Sir, your faithful friend and servant, J. CURRIE. The following Letters on the Plan for ereaing a Lunatic Asy- lum, at Liverpool, having been several times applied for by persons engaged in similar undertakings, are now given to the public at large. Liverpool, August 29th, 1789. Mr. Gore, Printer of the Liverpool Advertiser, Sir,—Be so kind as to give a place in your useful paper to the fol- ing remarks on public charities, and particularly on the proposal for a Lunatic Asylum. In forming an idea of the conneaion between the various ranks of society, we may consider a nation as a great trading com- pany, and if we suppose this company to be engaged in both ma- nufaaures and commerce, these terms will, in one sense or other, apply to almost all the occupations of civilized life. Each partner in the business is not equally concerned, it is true, because every one does not throw the same share of property, talents, and aaivity, into the common stock, but all are interested in the general suc- cess and the welfare of each is conneaed with that of the whole. A business of this kind naturally divides itself into various branches, in which the different partners must engage according to their respeaive knowledge and abilities. That there may be regularity and order, there must be a proper subordination ; each must exert himself honestly in his particular department; and while some plan to regulate, others must labour and execute. Of these two divisions, the last indeed is by far the most nume- rous. A few suffice to give general direaions, but many are re- quired for the manual operations. The manufaaures carried on are almost all of them from raw materials, and demand much time 4*5 and labour to bring them to perfeaion, and the exchange of these manufaaures, with those of other great trading companies, is busi- ness of great enterprize and exertion. The earth is hard and stubborn, the ocean is dark and tempestuous. To conquer the ruggedness of the one, and to triumph over the dangers of the other, the great bulk of mankind must work and toil. It is in- deed evident, that the various classes of men grow more and more numerous the lower they descend. A well regulated society may be compared for its solidity to a pyramid. It may be com- pared to a pyramid likewise because it terminates in a point, be- cause the strata of the building are of greater circumference as they approach the ground, because each inferior stratum, sup- ports all that are above it, and because the lowest stratum, which is the widest, sustains the building : here the analogy fails. The foundation of a pyramid becomes more solid, the greater the su- perincumbent weight. It only sinks the deeper in the earth. But the foundation of this living edifice is made of less firm materials, and if it be too much pressed upon, it will crumble away. This comparison may serve to illustrate the immense conse- quence of the labouring poor. They demand our constant atten- tion. To inform their minds, to repress their vices, to assist their labours, to invigorate their aaivity, and to improve their com- forts :—these are the noblest offices of enlightened minds in su- perior stations; offices which are of the very essence of virtue and patriotism, which must attraa the approbation of the good and wise, and which will obtain the favour of the Eternal Being, who is the Great Father of us all. But of all the claims which the poor have upon us, there is none so pressing, or so generally admitted, as that for assistance when sinking under disease. Accordingly, institutions for the relief of the sick poor have been established all over the kingdom, and are perhaps the most unexceptionable of all public endow- ments. In this great and increasing town, institutions of this kind have been supported with singular liberality, and have been attended with singular success. One disease only has no provision for it; one disease, awful in its appearance, and destruaive in its influence, but of so peculiar a nature as not to admit of relief un- der any general establishment. It is needless to say that this is Insanity. *The difficulty and expense of founding Asylums for Lunatics, have been the only reasons, it may be presumed, why they have not been universal, since it cannot be doubted, that they have the same general recommendations as hospitals for the sick, and that they even have peculiar claims in their favour, both of policy and of humanity. 416 Of the various evils to which men are subjea, there is indeed none so dreadful as insanity. Other calamities are exterior, and pass away with the flight of time; or if they are mental, they yield to the constant succession of external impressions. If hu- man nature is unable to throw off other evils, it happily sinks under them, and death presents itself to the good and the brave, as the termination of calamity. But madness, while it hastens not the approach of death, destroys all that makes life valuable. It is not a single enjoyment, of which it bereaves us, nor a single blessing that it carries away. It preys not on the gifts of fortune, but on the attributes of reaspn, and strikes at once at all the pow- ers and privileges of man ! Yet if the viaims of this fearful mila ly were incapable of re- lief, as some rashly imagine, we should have only to tremble at their fate, and to mourn over the degradation of our nature. But while experience teaches us that their situation is by no means hopeless, as men and as Christians, we are called on to exert our- selves in their behalf. If affliaion of any kind engage our atten- tion, if disease in any form excite our compassion, let not those be denied our pity and our succour, whose afihaion is the most deep, and whose disease is the most terrible. In the institution of a Lunatic Asylum there is this singularity, that the interests of the rich and poor are equally and immediately united. Under other diseases the rich may have every assistance at their own homes, but under insanity, relief can seldom be ob- tained but from an establishment for the treatment of this parti- cular disease. Hence the objeas of a Lunatic Asylum are two- fold—to provide accommodations for the poor suitable to their circumstances, and to make provision for those of superior sta- tions, who are able to remunerate the expense. The objects of such an institution are two-fold in another sense: It holds out a shelter both for the curable and incurable. To the first it proposes the restoration of reason, and while it relieves society from the burthen of the last, it covers the hapless viaims themselves from the dangers of life, and from the selfish contempt of an unfeeling world. A Lunatic Asylum differs from hospitals for the sick in another important particular. These require not only a great expense for their original establishment, but a great annual con- tribution for carrying them on, since the patients in hospitals have not only their lodging and attendance gratuitous, but their food also, and sometimes their clothing. On the contrary, in a Lunatic Asylum, the expense of diet and clothing (except in very particular cases) never falls on the institution ; this being de- 4^7 frayed for the paupers, by the parishes to which they belong, and for those in better circumstances, by the guardians of their pro- perty. It is the policy of an asylum to make these two classes con- nea with each other, so that the increased' payments made by the rich, may serve to diminish in some degree, the demands on the poor. Hence the annual expense of an Asylum is small, compared with that of hospitals, properly so called, though the expenditure required for the ereaion and fitting up of the building must no doubt be considerable. But it is not the charaaer of the inhabi- tants of Liverpool to let a plan for a public institution that can be proved to be useful or honourable, fall to the ground, for want o£ cOntributionsto carry it on ; much less, a scheme of humanity so interesting and important. Let the usefulness of this scheme be made apparent to the public, and its success is infallible. Every informed mind must indeed rejoice, that the general meeting called at the Infirmary to consider of the propriety of an Asylum for Lunatics, were unanimous in their approbation of the measure, and that a committee appointed by that meeting, are now preparing a plan for carrying it into effea. If the funds for the Asylum can be raised, without infringing on the interest or property of the Infirmary, the friends of that hospital will doubt- less rejoice to see the institutions conneaed together, by which mutual advantages may be obtained, and the great objea of all such charities, the relief of human misery, be promoted and ex- tended. The only other point to be considered, is the extent of this Asylum. The most prudent condua will be, not to enlarge it much beyond the present necessity, but to erea it on a plan, which may admit of future additions, according as future expe- rience may point out that they are required. Under these restriaions it is to be hoped that the public voice will be unanimous in favour of the proposed establishment: and that the magistrates especially, will lend it their support. So shall another evidence be reared, in addition to those which already reflea credit on the munificence of Liverpool. Our public build- ings for pleasure, as well as business, are in a high style of ele- gance and splendour: our institutions for the care of man's pe- rishing body are already perhaps brought near to perfeaion;—our honours will be increased, and the system of our charities com- pleted, bv an institution for the health of his immortal mind. J. C. S3 4i8 October \5th, 178S. Mr. Gore, Sir,—It gives me pleasure to find, that my letter to you of the 25th of August, on the proposal for a Lunatic" Asylum, has been so far noticed, that its defeas have been discovered, and that some gentlemen are desirous of seeing them applied. I proceed therefore willingly to discuss those points which connea the sub- ject with our particular situation, and which the limits of your pa- per prevented from being included in my first address—It may seem, indeed, that as the measure has been approved at a general meeting called by the mayor, where the scheme proposed by the committee was examined and adopted, it is not now'necessary to enter further into the business. But as objeaions have been started from soirie respeaable quarters, and as several gentlemen of pro- perty and charaaer seem as yet to hesitate on the propriety of the measure, it may not be improper to consider it more particu- larly. 1. It is asked how our Lunatics have been hitherto bestowed, and what inconveniencies have been felt from the want of an Asylum. Hitherto such as have not been sent to a distance, have been confined in the Poor-house, a building ereaed for the reception of helpless infancy and of declining age, which contains within its waifs upwards of a thousand objeas of this description, and which neither has, nor can be supposed to have, proper accommodation for Lunatics, who require sa very peculiar a treatment. Hence the burthening of the Poor-house with the insane, has been at- tended by many serious inconveniences. It has introduced disquiet and disorder into the institution, when the Lunatics have been suffered, as is common, to run at large; and where they have been placed in confinement, no adequate provision or attendance having been provided for it, unhappy consequences have followed to those hapless beings over some of which humanity laments, and delicacy must draw a veil. In such a state of things, much couid not possibly be attempted for the recovery of reason; but the more moderate have been kept as quiet as possible, and some of the more furious have been sent away. The faculty who have attended the sick of this great hospital, and the com- mittee who have superintended it, have; done their duty faith- fully: it is only to be lamented, thnt the evil, on the present system, appears to be irremediable. When the Poor-house shall be relieved from the Insane, the exertions of the refpeaable ma- gistrates who are now so laudably employed in improving its re- gulations, will be more successful. Their attention being confined 419 to the proper objeas of this institution, they will then find it easier to extirpate vice, disorder, and guilty idleness, from this great family of the lowest and most ignorant class of society, to prepare the young for entering the world with habits of industry and sobriety, and to give comfort and quiet to the old, whose days of labour are past, and whose chief duty k is to prepare themselves for a future world. 2 It is said, that though an Asylum for Lunatics maybe de- sirable, yet that sufficient accommodation may be found for them without ereaing a building on purpose. Some have pointed to the present Hcruse of Correaion as a proper place, and others mention, that cells may possibly be appropriated to them in the new Jail. That any plan which would separate the Lunatics from the general mass of the poor, would be an improvement on the present system, it is but fair to allow; but to each of these pro- posals there are strong objeaions. To the first, may be offered the objeaions already stated, against complicating the discipline; of a Poor-house with that of au institution for the Insane, with which it has no alliance, it may be urged likewise, that the pre- sent House of Correaion when vacated, will be wanted for a fe- ver-ward to the Poor-house, to prevent the spreading of .those con- tagions which, with every care, will sometimes be introduced in- to the building, and sometimes generated within its walls. And rt may be added, that the House of Correaion is very unfit for an Asylum for Lunatics from its stxuaure and size, which a single glance will shew to be inadequate to the purpose, and from its si- tuation, which is exposed to idle curiosity and perpetual noise. On the other hand, the appropriation of any part of the new prison to the reception of the Insane, may be supposed a very crude notion. That great and scientific edifice is destined to a very different purpose; if it were not, no part of it could be a- dapted to incurables without considerable alterations; and who would seriouslv think of planting an institution for the recovery of reason, within the precinas of a jail ? The truth is, these proposals have proceeded from an imperfea notion of the design of a Lunatic Asylum. If its intention were merely to provide a prison house for the Insane, where they might be hid from the sight of their friends .till the grave should hide them for ever, such proposals would deserve consideration. But this is only one objea of an Asylum, and that one the least im- portant. It has the greater objea of restoring reason itself, an^ such notions do not correspond with this high design. 3. But, while these schemes appear too narrow, another has been proposed that seems to run into the contrary extreme. Some 420 warm supporters of the Lunatic Asylum, (particularly one gentle- man, who has the power and the will to give it most generous assistance), are of opinion, that it ought to be a distina institu- tion, placed in the country, though near the town, where it may possess the advantage of the purest air, with a considerable space for the amusement of the patients in different exercises, and for their occupation in gardening and other innocent and healthful employments, when their minds are sufficiently calm to be enga- ged in this way. To this proposal the difficulty and the expense of carrying it into effea, are the only objeaions, for it cannot be denied, that it is, in the abstraa, the best of all others. Dr. Hunter of York, in a letter to the writer of this, gives a decided preference to this plan, and earnestly wishes, that every county in the kingdom would adopt it.—His opinion is the more to be regarded, because it is founded on aaual experience, having him- self been the principal agent in establishing an institution on this plan in his own county, to which he is the sole physician.—The York Lunatic Asylum. But it is to be feared, that such a plan can only be successful when proposed as a county establishment, and it does not appear that Lancashire is likely to unite in a mea- sure of this kind. In Manchester, a Lunatic Hospital connect- ed with the Infirmary there has long flourished; and a similar establishment at Liverpool will probably answer every exigence that may arise, for many years to come. Should other districts of the county require in process of time similar establishments, they will doubtless, in this, as in other instances, follow the ex- ample of the leading towns. That the expense of a separate esta- blishment in the country may be fairly computed, let us attend to a few obvious faas. In the Asylum at York, the patients are di-* vided into eight classes, which pay according to eight different rates, regularly progressive, from six to twenty shillings a week. It may be presumed, that these rates defray the expense of main- tainance, and that the sums raised for this institution by contribu- tion, have been employed in the original purchase and improve- ment of the ground, in the building and furnishing the Asylum, and in the expense of a separate establishment. By the state- ment published on die first of January, 1788, these sums appear to be as follows: Raised by benefaaions - 9155/. legacies - - - 17IS colleaions - - 8,lJj -----in all 11,0867. There is uo account of any accumulating fui'd ; the York A-\- ium is adapted to sixty, or perhaps Tvonty patients.. 421 As the purchase of land, building, &c. cannot be expeaed to be cheaper in the vicinity of Liverpool than of York, a similar plan could not be executed here at a lower rate. And though we built a house for the reception of thirty patients only, yet, as the quantity of ground required, and the expenses of the esta- blishment, would not be much less, the sum of the expense could not be calculated at less than two-thirds of that of the York Asylum.—But it seems scarcely to be expeaed that 8,000/. should be procured for this purpose in the town and neigh- bourhood of Liverpool, where some of the leading men seem as yet indisposed to a Lunatic Asylum on the easiest and most economical plan. Should the opulence and public spirit of any individual, or of any combination of individuals convince the wri- ter, that his doubts are ill founded, he will heartily adopt this more extended scheme, and promote it by the best of his humble endeavours. In the mean time the plan approved at the General Meeting, seems deserving of every encouragement, not only as the simplest, and least expensive, but as the only one likely to succeed, and as one that bids fair to accomplish all the more im- portant objeas.—By combining the Lunatic Asylum with the In- firmary, there will not only be an immense saving of expense in the building itself, but in the annual disbursements. The same offices, apothecary, and board of economy will serve both, beside other advantages ; and for a third of 8,000/. all that is wanted may possibly be obtained. To this union the same objections do not apply, as to a house for Lunatics in conjunaion with the Poor- house. The discipline of an Infirmary, and of a Lunatic Asylum, have similar objeas, and require the same habits, and nearly the same degree of watchfulness and attention. The Institutions them- selves are closely allied in their nature; the first affords relief to diseases of the body, the second to diseases of the mind. That these are more nearly conneaed than is commonly imagined, it would be easy to shew, if this were the proper place to enter on such discussions. Madness indeed can only be called a disease of the mind, because its most striking symptom is the derangement of the intellea.—The disorder, it is reasonable to suppose on eve- ry theory, is seated not in the agent but in the instrument of thought, and to borrow an expression from the letter of the en- lightened physician already mentioned, a madman may be defi- ned, " a man out of tune." 4. This subjea must not however be dismissed without noti- cing an objeaion to the plan which has been adopted, that comes from a very respeaable quarter. It has been supposed that the vicinity of the Lunatic Asylum to the Infirmary might be hurtful to this charity, from the patient? in it being disturbed by the noise 422 of the Insane.—As this objeaion is an important one, it has been particularly examined. Where experience can be had, it is always safest to have recourse to it, and this has been done in'the pre- sent instance. On this particular point Dr. Hunter of York, Dr. Simmons, physician to St. Luke's Hospital, London, Dr. Eason, physician to the Infirmary and Lunatic Hospital at Manchester, v Dr. Moncrieff of Bristol, and Dr. Cleghorn of Glasgow, have been consulted, and the writer of this has also had ample commu- nication on the struaure and economy of Lunatic establishments with Dr. Gilchrist of Dumfries He has likewise, by the assist- ance of Mr. Christie of London, obtained a plan and an account of the Lunatic Hospital at Montrose. To detail the information contained in these letters would be tedious and needless; they are open to the inspeaion of any gentleman who may wish to peruse then, as well as a copy of the words in which the objeaion was stated. It will be sufficient to say, that on this point, the answers of such as have had experience, are clear and satisfaaory. In the Dumfries Infirmary, Lunatics were at first confined on the ground floor, under the same roof with the other patients, but their numbers having increased, a separate building has been e- reaed for them, which stands as a wing to the Hospital; and, as appears by a plan of the whole, at a distance from it of thirty feet. In this instance, the objeaion it is clear has never occurred. In Manchester the Lunatic Hospital k in close conneaion with the Infirmary, as those who have visited that town must have seen, yet here we have the express assertion of Dr. Eason, that no such inconvenience has been felt, and this account has been confirmed by Mr. Darbey, a very ingenious gentleman, who has seen the spot on which our Asylum is intended to be built, and who served the office of apothecary to the Manchester Infirmary for twenty years. Mr. Christie and Dr. Simmons mention that this objeaion was started to the vicinity of St. Luke's with the Lying-in-hospital, but that it was over-ruled, and that experience has proved it to be merely hypothetical. Yet by the plan of St. Luke's, which the former has been so kind as to send, the distance between these buildings is only forty feet. Between the Liverpool Infirmary and the projeaed Asylum, a distance of fifty yards, if necessary, inay be obtained. If to these instances we add, that the trustees of Guy's Hospital, with all the experience of other institutions before them, and with a fund that is adequate to almost any ex- pense, are about to erea a building in connexion with that Infir- mary exaaiy upon our plan, it is hoped that the danger appre- hended in our case, will no longer be feared. Every new scheme must expea to meet with objeaions, and he 4*3 whose judgment suggests them to him, does society a service id proposing them openly. If they are well founded, they may pre- vent an ill-advised projea, if they are founded in part they may improve a hasty measure, and if they are altogether erroneous, they will, serve to illustrate a wise purpose and a judicious scheme. Those gentlemen therefore who have openly opposed the plan of the committee, conceiving that a better might be executed, are to be applauded for withholding their assistance till their objec- tions are in some degree removed ; and such as have hesitated in their approbation of any measure of the kind, not perceiving the grounds on which it is supported, have done wisely to with- hold their countenance for further information.—That the scheme of the committee does not comprehend every possible advantage, it is but candid to allow; but this is in no respea singular. We must not rejea those advantages which are the best that can be obtained, because they are not as good as may be conceived, nor refuse a blessing, though it has some tinaure of alloy. Bounded in our knowledge as well as in our power, we cannot expea that the work of our hand shall have the attribute of perfeaion. To those who may be surprised that a measure which seems now so desirable, should not have been sooner carried into effea, the difference between the objeas of this and of other charities, may be pointed out. The cries of poverty and of sickness will be heard, but Insanity, alas! cannot make its complaint!--------- Hence the viaims of this disease have passed too much unre- garded, and when they have been noticed, they have been thrust from the sight into prison houses, whose secrets, if they could unfold them, might often " harrow up the soul." A late national distress has however forced the subjea upon general attention ; the example of Liverpool, there is good reason to believe, will speedily be followed by several of the principal cities in the king- dom, and among the happy consequences of the issue of that calamity, future times will probably enumerate a more general provision, and a more humane treatment of this hapless class of our fellow-creatures. The writer of this is not biassed in favour of the proposal for a Lunatic Asylum by his having been the author of the scheme. On the contrary, it was proposed originally without his know- ledge; that honour belongs exclusively to others. But as there is a public, as well as a private duty attached to every station of life, when this proposal was brought forward, he conceived it carne within the scope of his professional duties to form a judg- ment upon it on the best information in his power.—The grounds of this judgment he now l.iys before the public, and he has the satisfaaion of thinking, that though this may appear an useless 424 labour, it cannot possibly do harm.. If the scheme is a good one, it cannot be too nicely examined: it is the charaaer of truth and wisdom' to appear more advantageous the more they are seen, it is for fraud and folly only to shrink from the light. J. C. P. S. Since writing the above, I have been favoured with a letter from Dr. Hunter of York, in which he has been so kind as to reaify one or two misapprehensions respeaing the Asylum for Lunatics there. He mentions, that instead of sixty or seventy, this building, with the last additions, will contain ninety patients, and that the sum total of its expense is something more than 10,000/; 1500/. having been laid by for additions and repairs, a circumstance not mentioned in the reports of 1787, from which my statements were drawn. Dr. Hunter is farther of opinion, that a separate building and establishment for thirty Lunatics, in the neighbourhood of this town, might be reared for a much smaller sum than what I have supposed, conceiving no doubt, that the experience derived from the Asylum at York, which was in a great measure a new under- taking, would point out a less expensive method of attaining the objeas in view. Though I have argued on the supposition of a building for thirty patients only, yet, I am of opinion, that we ought not to erea one for less than forty, the grounds of which shall, (if ne- cessary), be laid before the public on some future occasion: and thpugh in deference to this learned and respeaable physician, (whose kindness and liberality are worthy of every acknowledg- ment), his opinion is published as well as the faas he has offered, yet my predileaion for the plan adopted, of conneaing our Asy- lum with the Infirmary, as the best that can be pursued in our circumstances, continues as firm as before. In treating on this subjea the following faa, (which came very lately to my knowledge), ought to find a place, as it may serve to illustrate more strongly the propriety of some establishment for the Insane. It appears that Mr. Howard visited Liverpool several years ago, and witnessing the situation of the Lunatics in our Poor-house, that he was impressed with our want of a separate building for their reception. This it should seem, dwelt on his mind, and some time afterwards he wrote a letter to the Mayor of that year, (Mr. Pole), from Constantinople, recommending the ereaion of a Lunatic Asylum, and offering fifty pounds towards it, whenever it should be undertaken, a sum which his executors would be instruaed to pay, on produaion of the letter, should his life br 425 be demanded of him before his return. Hence the name ot John Howard of Cardington graces our subscription list. Mr. Howard has since been in Liverpool, and though he had much conversation with the writer of this, as well as with others, on the subjea of our charitable Institutions, it does not appear that he took any notice of his own remarkable offer. He learnt how- ever that the scheme for ereaing a Lunatic Asylum, had been brought forward by a public-spirited gentlemen, and though de- ferred for some time, that it was likely in the course of a few years to be carried into effea. Mr. Howard is again gone abroad, and should he live to return and visit Liverpool, it is hoped that in this particular he will not be disappointed. But this is a plea- sure which it is feared he may never enjoy.* Having awakened the powers of reason, and the true spirit of charity throughout the nations of Europe, he is now attempting to diffuse them among the disciples of Mahomet. While the sovereigns of Russia and Germany, are carrying devastation and slaughter along the coasts of the Euxine and the shores of the Archipelago, this Prophet of Mercy, approaches the benighted followers of the Crescent, from another quarter, with a mission of peace and love. He was last heard of from Petersburgh. Thence passing through Moscow, he purposed to enter the Tur- kish empire eastward of the sea of Azof, to avoid the storms of war. The route he has marked out crosses the mountains ot Circassia, and passes along the shores of the Caspian into Persia and Armenia. His pilgrimage will then extend across Arabia Petrea, and through the Isthmus of Suez into the continent ot Africa. If life is granted him, he will traverse the nations that inhabit the southern shore of the Mediterranean, and passing into Europe by the streights of Gibraltar, return by Spain and France to England. To this singular tour he has devoted three years, and he himself, it is said, has little expeaation of living to go through it. It is most probable, therefore, that we shall not see him again. —But no matter—wherever he finds a grave, the spot will be hal- lowed, and his name consecrated in the admiration of posterity. <%uo nihil majus, meliusve terris Fata donavere, bonique Divi; Nee dabunt, quamvis redeant in aurum Tempora priscum Hor. Liverpool, \2ihNov. 1789. JA. CURRIE. N. B. The Lunatic Asylum was completed in the year 1790, nearly on the plan recommended above. It has accommodations * He died on this journey at Cherfr; J C. 54 426 for sixty-four patients. No inconvenience has been ever experi- enced from its vicinity to the'Infirmary. May 7th, 180*. J. C. PREFACE TO THE LETTER TO DR. BEDDOES. HAVING in my dedication to Sir Joseph Banks mentioned the use of the Nitric Acid, as a remedy in Lues Venerea, I think it right to give the following letter to Dr. Beddoes, as containing the result of my trials of it at the time the letter was written—my subsequent experience is of the same mixed nature. I have not used the Nitric Acid as a remedy in fever—some of my friends have tried it in that disease, and thought it salutary. May Hth, 1804. Letter to Dr. Beddoes, on the Nitric Acid. Liverpool, 1st OElober, 1798. Dear Sir, I am truly sorry I have occasioned you the trouble of writing so often to me, by negleaing to comply with your wishes respect- ing the nitric acid; but the truth is, my experience of its effeds in lues is not so extensive, or so uniform, as to enable me to speak with confidence on a subjea where accurate conclusions appear to be so difficult. Nevertheless, since you desire it, I will give you a short account of what I have observed. I began to use the nitric acid in lues, at our hospital, in the be- ginning of 1797. In the two first cases, there were ulcerations on the penis, and open buboes in the groin, but no decided evidence of the system being affeaed ; and the disease was in each case of less than three months standing. In the third, the disease had been in the habit upwards of a year; the surface was covered with venereal eruptions; the throat had been affeaed, and the glands of the neck, on each side, had been indurated, and were in a state of open ulceration. The patient had undergone a course of mercury in the hospital; but after pushing it as far as her sys- tem would bear, she had been discharged, about six weeks before, with little or no amendment in her symptoms. The last six weeks she had been in the country, on a milk diet, and her health was somewhat recruited. I paid much attention to these three cases, and have minutes by me respeaing them, of considerable extent. The two first were males. 427 Each of the men took a pint of water daily, gratefully acidu- lated with nitric acid ; a drachm being at first used in each pint, and afterwards a drachm and a half; but this last proportion ap! pearing to affeft the bowels by griping, the original proportion was returned to, and the patients took a pint and a half of the acidulated water daily; i. e. a drachm and a half of the acid, as already mentioned. In the case of the female we never exceeded a drachm, her bowels being very irritable. In five weeks, every symptom of disease in the two men was gone; and I presented them to the Board, as remarkable instances of lues being cured without the use of mercury. Thev attended at my house weekly, for some time; but, being sailors, 'they went alterwards to sea, and I have never heard of them since. In the female, the same happy progress continued for nearly a month ; the eruption on the skin diminished, the noaurnal pains in the head and limbs went off, and the ulcerations in the neck assumed a healing appearance ; her general health, also improved rapidly. But at this period, her progress towards a cure stopped; and though we persisted in the acid some time, it did not recom- mence. It was therefore, at the end of seven weeks abandoned, and recourse had again to mercury, but in small doses, gradually increasing them, however, till ptyalism commenced. At first, there were indications of benefit from this new course of mercury; but these speedily failed; and her general health suffering severely, we were once more compelled to abandon it; the ulcerations in the neck having during its use, evidently spread and become more morbid. The nitric acid was had recourse to, as before. During the second course of the acid, her health again improved, and the venereal symptoms again appeared to give way. But, after a few weeks, these favourable indications failed us; we abandoned the acid, and resorted to mercury once more. It would be tedious to particularize farther. With the mercury, sarsaparilla, meze- reon, and opium, were successively combined; but in vain. Her health giving way, the sores enlarged, and Once more we returned to the acid. At length we combined the acid with mercury, in what are called alterant doses, and with evident benefit. At the end of eight months, however, the ulcerations continued, though much diminished. Despairing of any farther benefit from these combined powers, we abandoned them altogether, and after a proper interval, put the patient on a course of the mineral solution of De Valangin, (from which, in obstinate venereal affeai.ns, I had before seen extraordinary effeas) and during this course the ulcerations speedily healed, and the cure of the patient became complete, the treatment having occupied a space of upwards of ten months. In obstinate cases of this kind, it is usual to suppose, 428 that some scrofulous, or other taint, has combined with the vsne- real virus, and this may have been the faa in the present instance; the result will however, afford encouragement in similar situa- tions. The encouragement arising from the three cases just mention- ed, led me to try the nitric acid in a variety of other cases. In some of these, my success has apparently been complete; in others, there has been evident benefit without a perfea cure; and in others, it has seemed to fail entirely. It is not a little curious, that in some of the cases in which I have succeeded, the symp- toms were what are called secondary, and the disease in its most rooted and obstinate state. One of my patients, whose name is Elkins, has drawn out his own case, the particulars of which are shortly these:—About four years ago he was affeaed by lues, with the usual symptoms, for which he underwent a course of mercury, and was supposed cured. In about nine months after- wards, however, the disease appeared in his throat, and in obsti- nate pains in his head, &c. He was again salivated, and with si- milar good effeas. Twelve months after this, having been for a considerable time subjea to what was supposed to be rheumatism, the disease appeared again, and resisted the long-continued and repeated use of mercury, under a praaitioner here of the first eminence. He was at length obliged to abandon it, having been reduced to a state of extreme weakness. Abouf three months after this, he was admitted a patient into our hospital, and under my care. At this time he had a thickening of the pericranium in two different places, the most severe pains, especially in the night, in the bones of his head, arms, and legs, and a large in- creasing node on the right tibia. AU his symptoms were at this time increasing; and having taken so much mercury in vain, he was in a state of extreme despondence and depression. We prescribed the nitric acid, and his sufferings abated from the third day; and being continued, the thickening of the peri- cranium and the node of the tibia entirely disappeared, with all his other symptoms. He took the nitric acid, in all, to the quan- tity of eight oimces in eight gallons of water, which he drank in sixty days. Elkins has been nearly a year discharged, and has never had any return of his complaints. This case has made some noise, and I have endeavoured to attraa the attention of several of my .brethren to it, as decisive of the influence of the acid in this de- struaive disease. On the other hand, there are a still more considerable number of cases, in which the acid has entirely failed me, or produced 42y only partial benefit; and at present, though I always ordered it internally, with mercurial inunaions on the skin, I do not trust the cure to it alone in the first instance. Combined with mercury in this way, the constitution seems to support the aaion of the metal better, and the cure to be accomplished more safely and more speedily. In several instances where, after a course of the nitric acid, it has been thought advisable to have recourse to mer- cury, a very small quantity of the ointment, in one case two drachms only, has produced complete ptyalism. This has occurs red so frequently, that I do not think the conjunaion accidental. The nitric acid has never been pushed by me to the extent in which it has been used by others; in many of the cases, in which it has apparently failed, I cannot pretend to say, that it would not have succeeded, if pushed to a greater length ; but I have .not thought it proper to carry it to an extent injurious to the stomach or bowels, while the salutary effeas of mercurial inunaion re- mained untried. In the quantities in which I have prescribed it, it has been uniformly salutary to the constitution, in this respea its aaion contrasting very happily with that of mercury. In the cases in which it has apparently succeeded, (in my hands), in the cure of lues, I have not known a relapse to take place; but as the patients have been chiefly seafaring persons, it is not in my power to trace their history subsequent to our parting. In one case of the primary disease, in the hospital of the 20th regiment, the as- sistant surgeon, who thought it had effeaed a complete cure, found the disease break out in the throat, at the distance of four months, and finally removed it by mercury. I have experience of the effeas of the nitric acid in complaints of the stomach, hypochondriasis, asthma, and some other disea- ses, as well as in hepatitis; but as your inquiries are direaed to its agency in a single disease—lues—I forbear to enter on other points. *> But you will ask whether I can mark, by any particular effeas, the circumstances attending its salutary operation in lues ?—I think I can. In the cases in which it succeeded, it evidently ir- ritated the system in the following respeas: 1. The gums were always affeaed with tenderness and redness, and the aaion of the salivary glands increased. This affeaion mav indeed be considered as depending on its local aaion; for it took place in one case, where, for the sake cf the experiment, the acid was taken into the mouth, but not swallowed. This state of the gums, &c. was not attended by foetor, as during the aaion of mercurv, neither did it increase as the acid was conti- nued, but in a little while disappeared. This affeaion of the, 43° gums and salivary glands did not always appear in the cases where the acid failed. 2. In every case in which it succeeded or operated beneficially, there was a considerable increase of urine, and this discharge be- came turbid ; sometimes of a whitish, and sometimes of a brown- ish hue; it amounted to about eight pounds in the twenty-four hours. But the discharge of urine did not go on increasing un- der the continued use of th£ acid; on the contrary, it ceased like the increased discharge of saliva. The affeaion of the kidneys seemed to precede the affeaion of the salivary glands; but both the one and the other occurred by the fifth day at latest. 3. The patients had their appetites improved, and felt a great- er alacrity of spirits. 4. In all of them the pulse was rendered more frequent, and the animal heat towards evening increased from one to two de- grees, which in the night was generally carried off by more or less of sensible perspiration. I think that these symptoms have not appeared at all, or not in combination, where the acid has seemed to be inert. But I wish to speak with the diffidence becoming my imperfecl: experience; and I would not'willingly have spoken at all in this stage of the inquiry, had not there appeared a danger of the at- tention of medical men being wholly withdrawn from the investi- gation of a subjea, which, though difficult, seems to me not on- ly curious in itself, but likely to produce important consequences to the healing art. To assist in preventing this, I am willing to offer a testimony, which is certainly imperfea, and which in some respeas may ultimately be found erroneous. You are welcome* to make what use of it you please. I am, dear Sir, Yours with much esteem, J. CURRIE. THE END. ''^W:f-;C>f-** 11 05;t* .-r^-..- >: vW^W - -"•'T-'-' ;,-^~^-,^.^i . '■*■ * *=.. . .■■»; „;|l' ^--^i :. **>-. >?^;; ■-'•; v"':v ?f~ :-"'-;r-'-'■:'•>: ,•'•> ~^f;-_ -." ~ r~ ■5%-' -V-iT^..-:;:.-^; m&w® $&%■ ■ ■•■*'....... '■,-■■ •■>*