y r^— -:^.QfDr- Surgeon General's Office r^^ 'i1 /SMS, «!i £ ^^^l":^Qs^Q'2^^g^gQg^QaQ.gQr^ ** %$- *i~ A TREATISE ON FEBRILE DISEASES, INCLUDING INTERMITTING, REMITTING, AND CONTINUED FEVERS; ERUPTIVE FEVERS ; INFLAMMATIONS ; HEMORRHAGIES; AND THE PROFLUVIA ; IN WHICH AN ATTEMPT IS MADE TO PRESENT, AT ONE VIEW, WHATEVER, IN THE PRESENT STATE OF MEOICINE, IT IS REQUISITE FOR THE PHYSICIAN TO KNOW, RESPECT ING.THE SYMPTOMS, CAUSES, AND CURE OF THOSE DISEASES ; WITH EXPERIMENTAL ESSAYS, ON CERTAIN FEBRILE SYMPTOMS, ON THE NATURE OF INFLAMMA- TION, AND ON THE MANNER ON WHICH OPIUM AND TOBACCO ACT ON THE LIVING ANIMAL BODV. A. PHILIPS VVTLSON, M. D. F. R. S. Vfcjfc FELLOW OF THE ROYAL COLLEGE OF PHYSICIANJtpPDIJfBURC^&C. VOL. I. FIRS* AMERICAN FROM THE SECOND ENGLlSH'ibiritlM FIVE VOLUMES COMPRISED IN TWO. HARTFORD: PUBLISHED AND SOLD BY OLIVER D. COOKE. SOLD ALSO BY JOHNSON AND WARNER, PHILADELPHIA ; COLLINS AND PERKINS, NEW-YORK ; AND JAMES BURDETT AND CO. BOSTON. LINCOLN & GLEASON, PRINTERS. 1809. jrz CONTENTS. Page PREFACE,........9 INTRODUCTION,.......21 PART I. OF IDIOPATHIC FEVERS,.....45 BOOK I. Of intermitting and Remitting Fevers, 45 CHAP. I. Of the Species and varieties of Intermitting and Re- mitting Fevers, - - - - - - 45 SECT. I. Of the Varieties of the Tertian, 47 SECT. II. Of the Varieties of the Quartan and Quotidian, - 50 CHAP. II. Of the Symptoms of Intermitting and Remitting Fe- vers, ......- - 51 SECT. I. Of the Symptoms of Intermitting and Remitting Fe- vers, .......-52 1. Of the Symptoms of the Cold Stage of Inter- mittents, - - ... 52 2- Of the Symptoms of the Hot and Sweating Stages, -..,.... 55 SECT. II. Of the anomalous Symptoms of Intermitting and Re- mitting Fevers, - - -- - -58 SECT. III. Of the Diseases with which Intermitting and Remit- ting Fevers are most frequently complicated, - 61 SECT. IV. Of the Prognosis in Intermitting and Remitting Fe- vers, ...... - - 64 Of the Doctrine of Critical Days, 69 iv CONTENTS. SECT. V. Of the Symptoms peculiar to the different Types, 74 SECT. VI. Of the Manner in which the difiVrent Types assume more or less of the continued Form, - - 79 CHAP. III. Of the morbid Appearances discovered by Dissection in those who die of Intermitting and Remitting Fevers, 80 CHAP. IV. Of the Causes of Intermitting and Remitting Fevers, 82 SECT. I. Of the predisposing Causes of Intermitting and Re- mitting Fevers, ------ 82 SECT. II. Of the Marsh Miasma, - - - 83 SECT.m. Of the proximate Cause of Intermitting and Remit- ting Fevers, - - - - - - 91 CHAP. V. Of the Treatment of Intermitting and Remitting Fe- vers, ------- 92 SECT. I. Of the Treatment of an Intermitting or Remitting Fever during the Paroxysm, •- - - 92 1. Of the Means to be employed during the Cold Fit, - - - -'. . .93 2. Of the means to be employed during the Hot Fit, - ' - - ' - - 94 3. Of the Modus Operandi of the Remedies em- ployed during the Paroxysm, - - 105 SECT. n. Of the Treatment of an Intermitting or Remitting Fever, during the Apyrexia or Remission, - * 112 1. Of the Diet and Exercise during the Apyrexia or Remission, - - - . _ jj2 2. Of the Medicines employed during the Apyrex- ia or Remission, - - . . j|g 3. Of the Modus Operandi of the Medicines em- ployed during the Apyrexia or Remission, - 140 BOOK II. Of continued Fever, ... , 142 CHAP. I. Of the Symptoms of Continued Feyer, - - 143 CONTENTS. v SECT. I Of the Symptoms of Synochaj - - 144 SECT. II. Of the Symptoms of Typhus, - - - 146" Of the State of the Animal Functions in the Pro- gress of Typhus, - ... 147" Of the State of the Vital Functions in the Progress of Typhus, - - - - - 150 Of the State of the Natural Functions in the Pro- gress of Typhus, - - - - - 152 SECT. Ill Of the Crises of Fevers, - - - - 159 SECT. IV. Of the Prognosis in Continued Fever, - - 168 CHAP. II. Of the Remote Causes of Continued Fever, - 170 SECT. I. Of Cold as a Cause of Fever, - - - 170 SECT. II. Of Contagion, - - - - - 173 Of the Source from which Typhus springs, - i 74 Of the Ways in which Typhus spreads, - - 177 Of the Means of preventing the Generation and checking the Progress of Typhus, - - 182 CHAP. III*. Of the Proximate Cause of Fever, - - 194 SECT. I. Of Dr. Cullcn's Hypothesis, - - - 194 SECT. II. Of the Brunonian Doctrine, - - - 195 SECT. III. Facts relating to the Laws of the Excitability of the Animal System, in a State of Health and Disease, 211 CHAP. IV. Of the Treatment of Continued Fever, - . 224 SECT. I. Of the Means of stopping a Fever at it's Commence- ment by inducing a Crisis, .... 22 j SECT. II. Of the Treatment of Continued Fever, when we fail to induce a Crisis at its Commencement, - 239 1. Of the Treatment of Synocha, - - 240 2. Of the Treatment of Typhus, - - - 25f. VI CONTENTS. Recapitulation of the Treatment of Continued Fever, when we fail to induce a Crisis at its Commencement, 277 PREFACE to the second Volume of the English Edition, 279 CHAP. V. Of the Varieties of Continued Fever, - - 285 SECT. I. Of the Petechial Fever, 285 SECT. II. Of the Miliary Fever,.....286 1. Of the Symptoms of the Miliary Fever, 286 Of the Miliary Eruption, ... 286 Of the Symptoms which precede or attend the Miliary Eruption, ... - 288 Of the Febrile States in which the Miliary Eruption most frequently appears, - 289 2. Of the Causes of the Miliary Eruption, - 291 3. Of the Treatment of the Miliary Fever, - 294 SECT. III. Of the Aphthous Fever, ... - 300 1. Of the Symptoms of the Aphthous Fever, 301 Of the Aphthous Eruption, - - 301 Of the Symptoms preceding and accompanying Aphthae,......30? Of the Febrile States in which Aphtha; most fre- quently appear, - 309 2. Of the Causes of Aphthae, - - - SU 3. Of the Treatment of the Aphthous Fever, 314 SECT. IV. Of the Vesicular Fever, - 324 1. Of the Symptoms of the Vesicular Fever, 326 Of the Vesicular Eruption, ... 326 Of the Symptoms preceding and attending the Vesicular Eruption, ... 333 Of the Febrile States in which the Vesicular Eruption most frequently appears, - 329 2. Of the Causes of the Vesicular Eruption, 329 3. Of the Treatment of the Vesicular Fever, 331 SECT. V. Of the Erysipelatous Fever, - 332 I. Of the Symptoms of the Erysipelatous Fever, 333 Of the Erysipelatous Eruption, ... 333 Of the Symptoms which precede or attend the Erysipelatous Eruption, ... 335 Of the Febrile States in which edge is extremely deficient. There are few instances in which we can form even probable conjectures on this subject, and very few indeed in which we have any certain knowledge. In gener- al therefore I shall employ little time in considering the proxi- mate cause of diseases. It will be necessary now and then to point out the errors of prevalent opinions ; and we shall meet with a few instances in which observation has afforded some real knowledge respecting the proximate cause, which is not to be overlooked. The common definition of the proximate cause is exceptiona- ble ; since, in some instances, it applies to the remote causes. If we apply a considerable degree of pressure to the brain, by the finger for example, on the unossified bregma, apoplexy is the consequence. The degree of apoplexy is proportioned to the degree of pressure, and the pressure removed, the apoplexy ceases. The above definition of the proximate cause applies in this case then to the compressing force. It is not the conipres- sing force, however, but the change it induces on the brain which is here the proximate cause ofthe apoplexy, the compres- sing force being evidently the exciting cause. It must surely be granted, that the proximate cause of diseases exists in the body ; but the compressing force, in this instance, is external. A very slight alteration of this definition, however, removes the objection. The proximate cause may be defined, That state of the whole or any part of the system, which when present cau- ses, removed removes, and changed changes, the disease. The proximate cause of dropsy, for instance, is in many cases a de- bilitated state ofthe vessels, in consequence of which the exha- lation being increased, and the absorption diminished, watery col- lections are formed. According to this definition of the proximate cause, every dis- ease has several proximate causes. In the jaundice, for exam- ple, the definition applies to the accumulation of bile in the liver and gall ducts; it also applies to the biliary calculus sticking in the duct; if the presence of the stone in the duct is owing to a preturnatural constriction there, which is sometimes the case, the definition also applies to this. In cholera it applies to the increased action of the liver, and to the presence of an unusual PREFACE. 15 quantity of bile in the alimentary canal, &c. Some attempt to confine the term proximate cause to that which immediately! that is, without the intervention of other causes, produces the symptoms of the disease. But there is no common cause which immediately'produces the symptoms of a disease. Each symptom has its own proximate cause, which has no share in producing any other symptom of the complaint. Thus in jaundice, the im- mediate cause of the pain is the irritation of the duct; the im- mediate cause of the yellowness is the presence of bile in the circulating fluids ; and of costiveness, the want of it in the in- testines. But is there not, it may be said, some cause, the last in the chain of proximate causes common to all the symptoms, which should be regarded as the immediate cause ofthe disease? When such a cause can be distinctly traced, it doubtless deserves exclusively the name of proximate cause ; this, however, can very rarely be done. And when we find any cause, to which it can be proved that the above definition applies, we are more fortunate than we are. in nine cases out of ten. With regard to the ratio symptomatum, that is, the application ofthe proximate cause of a disease to trace the proximate causes of its symptoms ; or when we are ignorant of the proximate cause of the disease, of our general knowledge of the animal ceconomy to trace the proximate cause of some of its symptoms; our knowledge is very defective. In most diseases indeed, the causes of some symptoms readily suggest themselves. If we meet with bilious vomiting, we are at no loss to account for the nausea which preceded it; if the internal fauces are swelled and inflamed, we readily explain, and could have foretold, the diffi- culty of deglutition which attends these symptoms. When the cause of any symptom is thus evident, it requires little comment; when it is not, all that we can say of it is, in most cases, but con- jecture. It is evident we can never give the ratio symptomatum of any disease fully, till we are acquainted with its proximate cause. This consideration alone is sufficient to convince us, how unsuccessful our attempts in this part of the subject must gene- rally prove. In attempting to trace the proximate cause of diseases, and still more in giving the ratio symptomatum, we are often assisted by observing the morbid appearances discovered by dissection after death. These are also frequently useful by tending more directly to point out the proper treatment of the disease. I say more directly, because every thing which tends to elucidate the proximate cause and ratio symptomatum, tends unquestionably to improve the treatment. It will often be necessary for us there- fore to attend to the morbid appearances discovered by dissection after death. In giving an account of these, there are three things which particularly demand attention. We must endeavour to distin- 1« PREFACE. guish those changes which have been the cause of death, from those which were the cause of the disease; such as were the cause or consequence of the disease, from such as take place after death, and which are different in different circumstances; and such as were the cause or consequence of the particular com- plaint of which the patient died, from such as were connected with other disorders under which he had laboured. In these respects authors have been extremely negligent, often not even attempting to point out such distinctions. So that in giving a detail of the morbid appearances connected with particular dis- eases, (except when the change of structure observed is evidently such as must have produced the symptoms preceding death) much accuracy in these particulars cannot always be expected. But it is only in proportion as these points are ascertained, that we can make any use of the knowledge we acquire by opening bodies. In those cases, where no such distinctions can be made, our observations may prove useful to our successors, who will be enabled to make these distinctions in proportion as medical science becomes more perfect. To ourselves they are quite useless. All the knowledge we derive from attending to the symptoms and causes of diseases, may be regarded as useful to the physi- cian, only as far as it conduces to improve their treatment. It is not long since it was common with physicians to pretend, in most instances, to a knowledge ofthe proximate cause, and to boast of establishing on this foundation alone their rules of practice. But a juster mode of reasoning has convinced their successors, that they are able, in very few instances indeed, to determine the proximate cause of diseases; and that even in these instances, from the want of an accurate knowledge ofthe operation of reme- dies, they cannot with any degree of certainty determine, a priori, the modes of practice which will prove most successful. Had we a perfect knowledge of medicine, such a work as that I am engaged in would be superfluous. There would then be. no need for what is termed a system ofthe practice of medicine. A knowledge of another branch of the science, of the theory of medicine, of that branch which teaches the nature of the differ- ent functions of the body, the changes induced on them by dis- ease, and the operation of the different means found capable of restoring their healthy state, would enable us to make the best use of every remedy we possess. But so deficient is our know- ledge of the theory of medicine, that it often proves but of little use in practice. In many cases we have little else to conduct us in the treatment of diseases but the knowledge of what has former- ly proved beneficial or hurtful. This is the most valuable infor- mation which the physician can acquire. It is the deficiency of our knowledge which renders a system of practice necessary ; but this deficiency is so great, that such a system must at present be regarded as the most important branch of medicine. PREFACE. 1*7 r AlthAugn ire are unable to deduce the proper treatment of dis- eases from our knowledge of the different functions of the body, of their condition in the various complaints we are subject to, and the modus operandi of remedies, yet there are certain principles which regulate the treatment of many diseases, or even sets of diseases. With these it is of great consequence to be acquaint-1 fed. They not only assist the memory, but in some measure serve, instead of a more perfect knowledge, to direct our prac- tice in those diseases which have only lately made their appear- ance, or been distinguished from others, and of the treatment of which consequently our experience is but imperfect. ,These principles I shall take pains to trace as we proceed in considering the different orders of febrile diseases. The best way of assisting the memory in recollecting the dif- ferent means employed for the cure of diseases, is dividing these means into different heads ; pointing out the different ends we have in view in prescribing our remedies ; and arranging togeth- er the means which have been found to answer each of these ends. This is what in medical language has been termed forming and. fulfilling indications of cure. It is common to subdivide the means of fulfilling each indication ; and some have carried their divisions much farther, by which they have involved themselves in several difficulties. Their divisions and subdivisions have sometimes become so numerous, that so far from assisting the Inemory, it is easier to remember the treatment of a disease, without any arrangement at all, than their mode of dividing it. Besides, our knowledge is too imperfect in almost every instance £9.admit of such minute division, so that wherever it is attempt- ed it is founded more or less on hypothesis. • It is evident, that before we can lay down any indications of cure, (except such as are so general that they hardly deserve the name and are quite useless) we must know something, both of the nature ofthe complaint, and of the operation of the .remedies we are about to employ. If both the nature of the complaint, and the operation ofthe remedies that relieve it, be wholly unknown ;' If our. practice, as we shall find it in many instances, be wholly empirical, we cannot with any propriety lay down indications of cure, because they must then rest merely on the supposed nature 6f the disease, and the supposed operation of the remedies. Even in these Cases indeed it has been customary to lay down indi- cations, but they have always misled, and often been the source of much mischief. . In considering the treatment of diseases then I shall avoid nu- merous divisions. When our knowledge admits of it, I shall lay down indications of cure, and consider the means of fulfilling them,; when it does not, I shall attempt some other mode of ar- rangement, which .may equally, assist the memory, and tend less Vol. L C IS PREFACE. to mislead. I shall not spend much time in considering remedies which have proved unsuccessful, or old modes of practice which are now abandoned. It will sometimes be proper to take notice of some of these, in order to warn against popular errors, and it will sometimes be of use to compare former modes of practice with those which have superseded them. But for the most part we shall find, that time may be better spent than in discussions of this nature. It is not only the most concise and simple, but in general the most useful way of laying down the mode of treat- ment in any diease, to give only the result of our experience in it; merely to point out that mode of practice which has proved most successful, together with the rational attempts which have been made to render it more so. The modus operandi of remedies is the only head relating to the knowledge of diseases that remains to be mentioned. As we proceed I shall occasionally lay before the reader what appears to be ascertained in this part ofthe subject. Such is the plan I shall follow in considering the symptoms, cau- ses, and cure ofthe diseases I mean to treat of. A few general observations on my plan still remain to be made. It is common with those who write, as well as those who deliver lectures, for the instruction of medical students, to speak as if all they say were the result of their own observation alone ; and this they do, not from any inclination to deceive, because they cannot for a moment hope that every thing they say will be regarded as having been unknown till ascertained by their observations, or that they themselves should be supposed to have seen all the va- rieties of diseases which they have occasion to mention. Provi- ded they advance nothing but what has been thoroughly ascertain- ed, they think it in general unnecessary to point out, or perhaps have forgotten, the sources from which they derived the informa- tion. This is attended with more than one inconvenience to the stu- dent. His knowledge becomes confused and inaccurate, which it must always do when he is at a loss to discover the sources of it, by having recourse to which he may refresh the memory. This confused and inaccurate state of his knowledge prevents his ad- vancing any thing with confidence, and at length even himself trusting with confidence to what he believes ascertained, but can neither point how, nor by whom. This mode of writing not only tends to render the student's knowledge inaccurate, but deprives him of an opportunity of becoming acquainted'with medical au- thors, so that when he comes to be engaged in practice, he finds himself unacquainted with the merits, often even with the names of authors, which are the only source whence he can derive assist- ance. These considerations have induced me to make frequent reference to the best authors, and never to advance any thing which contradicts generally received opinions, or is not general* PREFACE. 19 ly known, without a reference in support of it to the work of some author whose accuracy may be depended on. I once intended to subjoin to each disease a short account ofthe best authors on it, to be met with in this country. It will answer every purpose to make frequent references to the authors of most importance, at the same time referring to those of less note, when I have occasion to quote from them any factor observation of con- sequence. Certain subjects will now and then present themselves, which (as they are less generally useful than most others) it will be pro- per to pass over without entering into a particular consideration of them- When this is done I shall refer to works, from which those who wish for a more accurate knowledge of such subjects may acquire it. By these means an opportunity will be offered of making out a list of writers on the different complaints I shall have occasion to consider, and likewise of becoming in some mea- sure acquainted with their works. I shall endeavour by attention to method, and adopting in ev- ery instance the simplest mode of arrangement which the subject seems to admit of, to adapt the following work to beginners ; and by comprising into a small compass a number of useful observa- tions, to render it not unworthy the attention of the more advan- ced student, and an useful compendium to be occasionally consult- ed by the practitioner. I shall on this account avoid the narration of cases, and as much as possible the discussion of opinions, which consume much time. I shall endeavour on the other hand, however, to avoid a great degree of conciseness, which is improper where it is of conse- quence to use every means of assisting the memory. The most effectual way of assisting the memory perhaps is endeavouring in every instance to account for phenomena of diseases, and explain the operation of the means which relieve them ; for even ill found- ed hypotheses may be useful in this way. The injury done by them, however, more than compensates for any advantage of this kind. We must therefore look for other means of assisting the memory. This will be done in some measure by a simple mode of arrangement I shall also, with the same view, arrange togeth- er those diseases whose symptoms and treatment are similar ; Compare the diseases which most resemble each other, point out analogies, and endeavour to trace certain principles, which I have already had occasion to observe regulate the treatment of many diseases, or even sets of diseases. In the present volume I have endeavoured to free the different parts of the subject from hypothesis, which has been the bane of medicine, and at the same time to retain and enforce the max- ims on which the treatment of idiopathic fevers is conducted. 20 PREFACE. These are simple deductions from facts, and must be admitted inr dependent!}- of all hypothesis. Dr. Cullen has severely criticU sed Lieutaud for attempting a system of practice independent of hypothesis, and has justly observed, that he treats of diseases in so unconnected a manner, and speaks with so little precision, that his laborious synopsis may be regarded as nearly useless. But this is not owing (as Dr. Cullen, anxious to find an apology for introducing his favourite opinions, alleges) to the want of a general system, but chiefly to Lieutaud s having overlooked those maxims, which are nothing more than expressions for gener- alized facts, that greatly assist us in acquiring a knowledge of medi- cine, and the knowledge of which forms the distinction between the rational practitioner and the mere empiric. 1 have also en- deavoured to give the different parts of the subject a more me- thodical arrangement than we find in the works of those who have treated fully of fevers ; and attempted to simplify some of them, particularly the treatment of continued fever, more than has for- merly been done. But if in none of these respects I have done any thing deserving of notice, it will still be admitted, that if the following volume enable another, by moderate application, to acquire in a few weeks that knowledge which he could not otherwise acquire with- out much study, and for the acquisition of which, (prepared as I was by having previously studied the subject) I found a twelve- month's laborious application scarcely sufficient ; it cannot be re- garded as an useless publication : and this is my apology fou offering it to the public. I A TREATISE ON FEBRILE DISEASES, $c. INTRODUCTION. j^OME observations on the nosological arrangement of febrile diseases form a proper, and indeed a necessary introduction to the following work. I have in the preface explained what is meant by a system of nosology, and for what purpose^ it is in- tended. Dr. Cullen* divides all diseases into four classes. The diseases arranged under the first class are those 1 am to treat of. This class he terms Pyrexiae. It comprehends all febrile diseases. These he subdivides into five orders, Febres, Phlegmasia;, Exan- themata, Ilaemorrhagiae, and Profluvia. The class Pyrexias he defines, " Post horrorem pulsus frequens, *' calor major, plures functiones laesae, viribus pracsertim artuum " imminutis."t—The first order arranged under this class (the Febres) he defines, " Praegressis languore, lassitudine et aliis " debilitatis signis, pyrexia sine morbo locali primario."—The second order (the Phlegmasia;) is defined, " Febris synocha; " phlogosis; vel dolor topicus, simul laesa partis interna; func- " tione ; sanguis missus, et jam concretus, superficiem coriaceam " albam ostendens."—The third order of the Pyrexiae (the Ex- anthemata) Dr. Cullen defines," Morbi contagiosi, semel tantum " in decursu vitse aliqucm afficientes; cum febre incipientes; * Dr. Cullen's System of Nosology in every respect so greatly excels those which preceded it, that it will not be necessary to take notice of any other.—See a short view ofthe nosological systems of Sauvages, Limu.r.s, Vc^ciius, Sagare, and M'Bride, in the first volume of Dr. Cullen's Synop- sis JNosologiac Mcihodicx. f Characters of diseases are generally expressed in Latin, because it is diffieult to remember accurately what is expressed in the language employed for the common purposes of life: we are apt to change die mode of expression, and consequently often the meaning. « INTRODUCTION. « definito tempore apparent phlogoses, saepe plures, exiguae per « cutem sparsae."—His definition of the fourth order of the Py- rexiae (the Hxmorrhagiae)is, " Pyrexia cum profusione sanguinis tt absque vi externa ; sanguis missus ut in phlegmasiis apparet." —The last order of the Pyrexiae (the Profluvia) is defined, " Py- u rexia cum excretione aucta, naturaliter non sanguinea." Such is Dr. Cullen's mode of arranging febrile diseases. It is far from unexceptionable. I shall here point out in what I mean to deviate from this mode of arrangement, and my reasons for doing so; which will make the reader further acquainted with the plan to be pursued in the following work. The orders arranged under Dr. Cullen's class of Pyrexiae ma- terially differ from each other in the following circumstance. The fever in two of these orders (the Febres and Exanthemata) is strictly idiopathic, that is, exists independently of any local affection. It is true indeed that local affections accompany many of the idiopathic fevers. The Exanthemata are attended with eruptions on the skin ; but these appear a considerable time after the commencement ofthe fever, and cannot therefore be regarded as the cause of it. Besides, its degree is not at all proportioned to that of the local affection in these complaints ; in some of them so much the contrary, that the more violent the local affection, the milder in general is the fever. This is the case in the plague and the scarlet fever; nay where certain causes conspire to pre- vent the fever, the local affection of the Exanthemata is often present, and that to a considerable degree, without fever. This frequently happens in the plague, and sometimes in the small- pox, though not so strikingly, for there the local affection is in- considerable when unattended by fever. We shall find also, that in the Exanthemata, the fever, with all its peculiar symptoms, has often appeared without any eruption ; this is true of the plague, small-pox, and measles, and probably of all the other Exanthemata. So far indeed is the local affection in these complaints from occasioning the fever, that the latter generally suffers an abatement, and is sometimes wholly removed, on the appearance of the eruption. In the Exanthemata then, the fever is as truly an idiopathic affection as in fevers properly so called; and in laying down the practice in those complaints we shall find it treated as such. The first and third orders of Dr. Cullen's Pyrexiae therefore agree in the most essential point —in that which, we shall find, more than any other, influences our practice in febrile diseases. On the contrary, in the three remaining orders, (the Phlegma- sia, Haemorrhagiae, and Profluvia) we shall find, that the fever always accompanies some local affection ; being not only propor- tioned to it, but varying in kind as the local affection varies; and that the principles on which the practice in these orders of dis- INTRODUCTION. S3 eases is conducted, are so modified by this circumstance, as to differ widely from those which regulate the treatment of the Febres and Exanthemata. In the one set of diseases, the fever is the primary complaint; in the other, merely the consequence of some local affection. It cannot therefore appear surprising', that the principles which di- rect our practice in these two sets of diseases should essentially differ. In the former, our whole attention is directed towards removing the febrile symptoms; in the latter, the local affection demands our chief attention ; and experience has taught us that if we succeed in removing this, we at the same time remove the feyer which attends it. These circumstances considered, does it not appear a proper, and, if we aim at any degree of nosological accuracy, a necessary alteration of Dr. Cullen's mode of arranging febrile diseases, to divide his Pyrexia into two classes, the idiopathic, and the symp- tomatic, fevers ? To arrange the Phlegmasia after the Febres, and before the Exanthemata, (diseases so much allied to the Febres) and after considering the Exanthemata, to return to the Hamorrhagia and Profluvia, (diseases in their nature so nearly resembling the Phlegmasia) tends to perplex our ideas of the different orders of the Pyrexia. Why first consider the idiopathic, then the symp- tomatic, then return to idiopathic fevers, and then again to such as are merely symptomatic ? What induced Dr. Cullen and other systematic writers to adopt this mode of arrangement, seems either to have been, that they regarded the Exanthemata as complaints compounded of Fevers and Phlegmasia, and consequently considered it proper to treat of both the latter sets of diseases before the former ; or they thought that their account of the inflammatory affection which appears in the Exanthemata, would be more readily under- stood after treating of the Phlegmasia; and thus repetition be prevented, which it cannot be if we first describe the eruptions of the Exanthemata, and afterwards the different species of inflam- mation. The idea on which the former of these arguments is founded, is false, if by Phlegmasia we mean any thing more than a local affection, (as will presently more plainly appear) and may lead to errors in practice. The latter seems a better argument; for almost every thing we say, when we describe the Phlegmon in the small-pox, for in- stance, must be repeated in describing Dr. Cullen's first genus of the Phlegmasia, the Phlogosis. This objection to the mode of arrangement which I propose is considerable, but it is less so in a system of practice, than in a nosological system. In the former, for the sake of perspicuity, nearly the same description J4 INTRODUCTION. <->f the eruption in the Exanthemata is necessary, whether the* Phlegmasia have been previously considered or not. . But how- ever objectionable this mode of arrangement may be, it w certainly less objectionable than that of Dr. Cullen, who con founds, to- gether idiopv.hu- and symptomatic fevers, diseases so different in their nature, and requiring very difforc.it modes of practice. 1 j -re thm, turn whi h way we will, we find a barrier opposed to our advancement in nosological accuracy : A probable inference from which is, that we are not proceeding on a proper plan. The error seems to be, that we are considering the more complicated, before we have treated ofthe more simple, diseases. Not only the Pyrexia, but the Neuroses and Cachexia, ought to be placed after the affections which arc merely local, bytfatf the majority of which are cou^anlly occurring in the general and more complicated diseases. In this class of lo^-al diseases, Micro should be an order for sim- ple inflammations, for such inflammations as are hot attended by fever, as pimples, and that habitual and superficial redness of the face and hands which never produces fever. These affections arc trillinir, and on that account have often been overlooked, at least not treated of separately from other inflammati< ;is ; but however trilling the complaints themselves may be, properly ar- ranged they would prove useful in a system of. nosology, by ena- bling us to give a metliodical arrangement of more important diseases. Besides, such an order of simple inflammations would include-some diseases of importance, certain dpecies of. Ophthal- mia for instance, and the Aphtha Infantum. With what propri- ety are these, in which no kind of fever ever appears, ranked in the class of Pyrexia ? Not one symptom of these complaints is mentioned in Dr. Cullen's definition of Pyrexix. They mi^ht'as well be arranged under any other definition in the whole nosology. The Phlegmasia;, as defined by Dr. Cullen, are diseases com- pounded of simple inflammation and fever. There are thesame reasons,'therefore, for treating of simpte inflammation'before the Phlegmasia, which have induced nosulogists to arrange the in- flammations before the Exanthemata. But the latter^ also are compounded of simple inflammation and fever, not of Phlegmasia and fever. \\ hen a Phlegmasia supervenes on an Exanthema, the combination is of quite a different nature from that of the primary fever of the Exanthema and the simple inflammation which succeeds it. There is no better reason then (resulting merely from a view of-the complaints themselves) for arrangi,,:. the Phlegmasia be- teethei.xanthe.nata, th,n for arranging the Exanthemata before *e Phlegmasia. But smce both are complaints in which two more simple aflcctioi,s are combined, these should be considered INTRODUCTION. IS before cither. And since in the Exanthemata the fever is idio- pathic, they should be arranged with other idiopathic fevers, and consequently before the Phlegmasia. Dr. Cullen is led into several difficulties, by treating of the Phlegmasia without having previously considered simple inflam- mations. In the definition of the Phlegmasia:, Phlogosis is men- tioned ; but Phlogosis is a genus of this order, so that this disease is arranged under an order, of. whose definition it forms a part ; just as if we were to define the Exanthemata, fever attended with eruption, and then arrange eruption as a genus of the order. Besides, Phlogosis is the name of a disease, and is here used be- fore the disease has been defined. Dr. Cullen perceived the difficulty ; it is one indeed which it was impossible for him not to perceive, and he seems in this instance to have had recourse to a common subterfuge, a degree of obscurity. In the definition of the Phlegmasia he says, " Febris synocha, phlogosis," 8cc< evidently implying by Phlogo- sis, nothing more than an external inflammation unaccompanied by fever, and immediately after he informs us, that it is a febrile disease. If Phlogosis is made a genus of the Phlegmasia:, it must be a febrile disease } if not, there is no place for it in Dr. Cullen's system. It would have been easy for him in the definition of the Phlegmasia:, instead of the term Phlogosis, to have used some other, expressive of simple inflammation; but he must then have mentioned a complaint not to be found in his noso- logy. The same circumstance forces him into an error of no less consequence, in his definition ofthe Exanthemata. ' There again the wpfc of a term expressive of simple inflammation recurs, and he is again obliged to employ Phlogosis, which he has defi- ned to be a febrile disease. Phlogosis is an external inflamma- tion occasioning fever ; the eruption in the Exanthemata, instead of occasioning, usually even relieves, fever. Had Dr. Cullen treated of simple inflammations, as well as simple fevers, before the more complicated diseases, he would have avoided all the foregoing difficulties. There would have been no reason for interrupting the consideration of idiopathic fevers, to introduce the order of Phlegmasia:, which, as it stands in Dr. Cullen's system, can only be regarded as the sixth or seventh part of the whole nosology in a parenthesis. He would not have been obliged to confound in one class, dis- eases so different as idiopathic and symptomatic fevers. This he certainly would have avoided, had not his mode of arrange- ment rendered it necessary to place the Phlegmasia: before the Exanthemata, which he could not do without making one class of all kinds of fever. Vol. I. D *6 I.\TRO DUCT ION. He would not have been obliged cither to exclude from hi J system the simple inflammations, or to arrange the genera of this order among febrile diseases.* He would not have found it ne- cessary to employ the name of a disease before he had defined it, nor run into the inaccuracy (to use no stronger term) of ar- ranging as a genus under an order, a complaint the name of which he finds it necessary to use in the definition of that order. In short, febrile diseases (the most essential part of a system of nosology) would have admitted of a more systematic arrange- ment. Such are the circumstances, which have induced me to divide Dr. Cullen's Pyrexix into'two classes, the idiopathic, and symp- tomatic, fevers. I am now to make a few nosological observa- tions on each of these classes. The former, I have already had occasion to observe, compre- hends only two of the orders of Dr. Cullen's Pyrexix, the first and third, the Febres and Exanthemata. In every febrile com- plaint, which cannot be referred to one of these orders, the fever, we shall find, must be regarded as symptomatic. However different the symptoms are which distinguish the different genera of idiopathic fevers, there are certain symptoms common to all of them, and which may therefore be allowed to- constitute fever, or in other words to form the definition of this- class of diseases. Let us endeavour to determine what these symptoms are. We are informed by Van Swieten, that Boerhaave, with much labour, collected from a great variety of authors, all the symp- toms which they had observed in fevers. From these he threw out such as did not appear in all fevers, and was much surprised to find the catalogue of symptoms common to all kinds dfcver, so short. It reduced itself to the three following, shivering, or as it has been termed rigors, a frequent pulse, and heat. But it may be observed that no one even of these symptoms constantly attends fever. The shivering is almost always con- fined to the commencement of the fever, or to that of its ex- lcciOaliens, and sometimes is not observed at all. Both Boer- lK-ave and his commentator allow, that although the shivering is present at the commencement of fevgr, when arising from an internal cause, such as the pestilential contagion, the contagion 01 small-pox, Sec. ; yet when it arises from what they call an external cause, such as rage, violent exercise, &c. it often comes on without any sense of cold. . * Dr. Cullen might have formed an order in the Locales for simnl.. inflammations; but ntroducine them into anv m*+ i* w ? simP,e the Phlegmasia:, would hau- only rieredKSL i* * f T™- atter accurate definition ofthe PhleemSathe mJl ^ °t fo™inig an means of avoiding the difficult wS W £?„ aPParfnt , L he <»»r be making the Locales the fiSt cla*of flXJeT meuUoi,ed> *ems * MTRODVCTION vr Many of the ancients, although they did not wholly overlook the state of the pulse, as appears from several passages in the works of Hippocrates, seem to have regarded the last of the three symptoms just mentioned (the increase of temperature) as that which constitutes fever. It is well known, however, that in certain kinds of fever the temperature of the body often falls below the natural standard. In the commencement of the cold stage it generally does so, and very often in the progress of that species of fever which has been termed the low nervous fever. The shivering, or sense of cold, then, and increase of temperature, are symptoms, not only not present at every period of these complaints, but not even at any period essential to fever. Thus one symptom only remains to constitute the disease, a frequent pulse, and to this conclusion Boerhaave was led. But we must go a step farther, and observe, that although a frequent pulse is the most constant of all the symptoms of fever, it is not universally present in these complaints ; in malignant fevers the frequency of the pulse is often observed to be no greater, and sometimes considerably less, than natural. In these fevers the pulse has been found to beat only 40, sometimes o dy ">0, times in a minute. Besides, by considering fever as present wherever the frequency of the pulse is increased, we class to- gether the most dissimilar affections. With fever, for instance, we must class palpitation of the heart. The inference from these observations is plain, that no one symptom can be regarded as characteristic of fever. We ascer- tain its presence, not by attending to any one, but several of its symptoms. In selecting however the train of symptoms which characterise it, there is much difficulty.* The following is the selection made by Dr. Cullen : Languor, lassitude, and other signs of debility, followed by Pyrexia, (that is, by rigors, fre- quent pulse, increased heat, and derangement of the functions, particularly a want of vigour in the limbs) without any primary local affection. Although I quote this, as the best definition of fevers which has been given, even its author confesses its faults, but pleads justly the difficulty of the subject. The most exceptionable part is the definition of Pyrexia contained in it. Fever, it has just been observed, is not always attended by ri- gors ; even increased heat is not uniformly present during its progress. Increased heat, however, it is necessary to retain as * It is certainly impossible, by any enumeration ofthe symptoms of fe- ver, to give h short definition of diis complaint that will apply to ail periods of every kind of fever; and a long one would not answer the purposes of a definition. In a subsequent part of this volume I shall at- tempt ad^i.iitkm of idiopathic levers, constructed wn a different princi- jde. •3 INTRODUCTION: a part of the definition of fever, since it is very generally pre, sent, and the frequent pulse, without increased heat, often at- tends complaints of a very different nature. The derangement of the functions, particularly the debility of the limbs, docs not very properly enter into the definition; since the derangement of some of the functions is observable in almost all diseases, and the derangement particularly specified (the debility of the limbs) is frequently absent in fever,'in which indeed the vigour ofthe whole system is often preternaturally increased. Having arranged under the term Pyrexia so many diseases, Dr. Cullen found it necessary so to define this word as to express the striking characteristic features of a great variety of com- plaints. If we lay aside the term Pyrexia, (not attempting to class together so many diseases) we shall considerably lessen the difficulty of giving such a definition of idiopathic fevers, as shall apply to all cases. Dr. Cullen's mode of arrangement obliges him to introduce into his definition that of Pyrexia. By arrang- ing separately the idiopathic and symptomatic fevers, we get rid of this embarrassment. Idiopathic fevers, as far as I can judge, may be defined pretty accurately as follows :—Prxgressis lan- guors, lassitudine,et aliis debilitatis signis ; pulsus frequens, calor auctus, sine morbo locali primario. This is the definition of Dr. Cullen's first order of the Pyrexix, with this change, that pulsus frequens, calor auctus is inserted, instead of Pyrexia. He uses the definition as the character of an order, only comprehend- ing fevers properly so called. I shall use it, \with this altera- tion, as the character of a class comprehending both fevers pro-. perly so called, and the Exanthemata. Under this class may be arranged three orders ; Intermitting and Remitting Fevers ; Continued Fevers ; and the Eanthema^ ta. It will be proper to make a few observations on each of these orders. Dr. Cullen gives the following definition of intermitting and remitting fevers:—" 1 ebres miasrnate paludum ortx, paroxysmis «' pluribns, apyi exia, saltern remissione evidente, interposita: cum « cxaccrbatione notabili.plerumque cum horrore,redeuntibus, con. " stantes; paroxysmo quovis die unico tantuni." In this definition Dr. Cullen, very properly I think, includes both intermitting and re- mitting fevers; because (as he observes) these fevers arise from the same cause, are cured by the same means, and in the same person the lever olten changestrom the one formio the other. "Miasrnate paludum ortx" should be rejected from the definition. It is far from being ful.y ascertained, (as will appear hereafter) that intermitting and remitting fevers always arise from marsh miasma, even in those who have not formerly laboured under them ; while it is certain, that these complaints are often renewed by other causes, in those who have lately been afflicted by then,. Besides, we should confine ix:,c,ic3icul definitions as much as possible to what INTRODUCTION. 2t the practitioner can himself observe. The knowledge he de- rives from the information of the patient, or others, is always li- able to error. " Paroxysmo quovisdie unicotantum" ought also to be omitr ted, since both in intermitting and remitting fevers, there are often two paroxysms in the same day. Dr. Ctdlen seems to have introduced this part of the definition to assist in forming a diag- nosis between this set of fevers, and those termed continued. We shall presently see more clearly that it affords no mark of distinction between these complaints, and that such a diagnosis is not so necessary, as at first sight it may appear.' With these exceptions, Dr. Cullen's definition of intermitting and remitting fevers is extremely good, and sufficient we shrll find after the objectionable parts are rejected, for distinguishing the fevers arranged under it. It is simple and short, and at once directs the attention to the leading features of the complaint. The species and varieties of this order I shall presently have oc- casion to consider at some length. The second order of idiopathic fevers, that is, the second sec- tion of Dr. Cullen's first order of the Pyrexix, (continued fever) he defines, " Febres sine intermissione, nee miasmate paludum " ortx, sed cum remissionibus et exacerbationibus, parum licet " notabilibus, perstantes, paroxysmis quovis die binis." As " mi- " asmate paludum ortx" was rejected from the last definition, " nee miasmate paludum ortae" should be omitted in this. The latter part of it, " paroxysmis quovis die binis," is also excep- tionable, as this circumstance is seldom distinctly observed in continued fevers. Dr. Cullen observes, that since continued fevers consist of re- peated paroxysms, it may sometimes be difficult to distinguish them from remitting fevers; and this difficulty may seem in- creased by the changes I have proposed in his definitions. The truth is, that these two kinds of fever run into each other. The only difference, which can be specified between remitting and continued fever, is, that ofthe degree and length of their remis- sions. There is no symptom of the one, which does not occasion- ally attend the other. In this, howc.cr, and similar difficulties, we shall find, that when the symptoms of two diseases impercep- tibly run into each other, the same is true of the modes of practice suited to them j so that a perfect diagnosis between them is un- necessary, for nosology derives all its importance from its being subservient to practice. The ancients (Dr. Cullen remarks) mention fevers, in which there was not the least appearance of remissions thioughout their whole course. Such however are seldom if ever observed. In all fevers we generally perceive some degree of remission, at least once, sometimes twice, in the day. It is therefore to fevers with slight remissions, that we r.pply the term continued. Si* INTRODUCTION. Continued fever*, have long been divided into acute and chronic; and many disputes have arisen concerning this division. In acute fevers the symptoms are generally more violent than in chronic, and the disease is sooner terminated. Some have confined the term acute, to those fevers which terminate before or on the twentieth day. Others extend this period to sixty days; and Galen divides the acute fevers into acute, which extend to between the seventh and the twentieth day; and peracute, those \vhich terminate before or on the seventh. The peracute he subdivides into exactly peracute, those which are not protracted beyond the fourth day; and not exactly peracute those which extend to the seventh. * The acute he in like manner subdivides into exactly acute, those which terminate on the fourteenth day; and not ex- actly acute, those which are protracted to the twentieth. All these days, we shall find, were regarded by the ancients as chief critical days.* These divisions are altogether arbitrary, and of little or no use in practice. The division of continued fever into Inflammatory and Nervous, or, as they have been termed, Synocha and Typhus, is one of more consequence, and at present more generally adopted by physicians. It points out the only species of continued fever, which can be well defined ; and greatly assists us in laying down the mode of treatment in this varied disease. The following is Dr. Cullen's definition of Synocha, « Calor " plunmum auctus, pulsus frequens, validus, et durus, urina ru- " bra, sensorii functiones parum turbatx." Many objections might be started to this definition, but it would be difficult to tuve a better. In forming it, Dr. Cullen chiefly kept in view the cir- cumstances which distinguish this species of fever from the Ty- phus ; and he rather gives the symptoms of the more strong marked cases of Synocha, than of Synocha in general. The same observation applies to the definition of Typhus He rather gives the diagnostic symptoms of strongly marked Typhus, £?. S"u m -*araclen»? the generality of fevers referred \o this headI « Morbus contagiosa, calor parum auctus, pulsus parvus imn "' y16"1™'"6 *?*""* «™ P^um inutata^en^rK: » tiones plunmum turbatx, vires multum imminutx." Nor does it seem possiole to avoid this inaccuracy, since as Synocha and Typhus insensibly run into each otherf it is only in themore wrongly marked cases, that they can well be disthfguLed Tc Sm^" C3SeS °f Syn°Cha and T^hus>tl?-Is no fc. eve^te^ we rarely, if « first run, however well n^ked^t S^rh"^ Ta^T8 commencement of the complaint, the sv21.!?yT i. the -ys, at least in this country! shew ZZSXZ%££ [*£* * Days on which the great charts offerers most frequently happen. INTRODUCTION. 31 nation; and however well marked the symptoms of Typhus may be in the progress of fever, in almost every case the first symptoms are more or less inflammatory. On this account Dr. Cullen makes a third species of continued fever, which he terms Synochus ; and defines, " Morbus conta- " giosus, febris ex Synocha et Typho composita ; initio Syno- " cha, progressu, et versus finem, Typhus." The fevers mentioned by authors, under the names Synocha and Typhis, are in fact no other than varieties of the Synochus. When the symptoms of Typhus predominate, the fever has been termed Typhus; when the inflammatory symptoms are most remarkable, and present through the greater part of the com- plaint, it has been named Synocha. These varieties of continued fever so run into each other, the difference seeming often to de- pend on adventitious circumstances, that they are properly con- sidered as one complaint; wonderfully varied indeed, but be- tween the varieties of which no well marked line can be drawn. There are other varieties of continued fever, however, which in some respects are better marked. Although continued fever is not in general attended with any eruption, yet eruptions of dif- ferent kinds often appear in this complaint; and as they seem to modify its symptoms, or at least, as each particular eruption is apt to shew itself when a certain train of symptoms is present, they may serve to distinguish some varieties of continued fever. After physicians became acquainted with the Exanthemata ; after they had observed that a certain train of febrile symptoms are always followed by an eruption of a particular kind, and that every one infected by a person labouring under such a fever is seized with the same train of febrile symptoms, followed by the same eruption : I say after physicians became acquainted with these complaints, they, seem to have inferred, that wherever an eruption occurs in continued fever, preceded by, or attended with, a particular train of febrile or other symptoms, the complaint is an Exanthema ; that it is of a nature different from that of a common continued fever ; and that when communicated from ' one person to another, it would always be attended with its pecul- iar symptoms and eruption, as happens in the small-pox and meazles. Thus they regarded the Petechial fever, thus they still regard the Miliary, the Aphthous, and several other varies ties of fever, as Exanthemata. A more particular attention to these complaints has long ago (at least in this country) convinced physicians of their error, with respect to the Petechial fever ; and they begin to suspect it with respect to several others, which nosologists at present class with the Exanthemata. Let us consider the pretensions of each of those to the place it holds in our systems of nosology. Although Dr. Cullen gives the Miliary fever a place among the Exanthemata, he expresses his doubts whether it properly be- sz INTRODUCTION. lon^s to this order, or rnvv I r.ithf r say, be adduces sufficient a?' gumentsto prove that it docs not. '• There has lately been p " wi'-m dispute (he observes) concerning the nature of this fever, "particularly among the German physicians ; the one party « looking upon it as merely a symptomatic affection ; the other " asserting that it is as completely idiopathic as the small-pox or " mcazlto. " For m v own part (he continues) although I cannot in the face « of verv rcspcctab'c authoriiies, positively assert that it never iti " an idiopathic fever, yet since experience in such cases is often " fallacious, and physicians are too apt to adopt the opinions of " their predecessors, 1 cannot help expressing my doubts on this " point, ?.nd the more so, as 1 ha\e in many years practice found « this complaint for the most part-symptomatic. I have never "found it (he observes) contagious or manifestly epidemic; al- " though at certaih periods, I confess, I have known it more fre- " qucnt than at others. The miliary eruption appears in putiid " as well as inflammatory fevers, and at no time in any, except " when forced out by external warmth or sweats. Besides, in fe- " vers where from various circumstances the miliary eruption " was expected, 1 have known its appearance prevented by the cool- ie inn- regimem,and by avoiding sweats. In some parts of the body " I have even seen it induced as if by art. lastly, the matter ex- " citing the military fever, if there be any such matter, differs " widely from other exanthematic contagions, both in not causing " the eruption to appear about the same day of the complaint in " different cases, and in attacking the same person more than K once." Dc hujus igitur materia natura specifica, (he adds) " vel ad morbum quemvis idiopathicum gignendum apta, valde u dubito. In hac re raecum senlientem experientissimum " et pcritissimum Carol. White habere mihi gratulor. Vide " White on the Management of Lying-in Women."! Dr. Cullen, to overcome the difficulty as far as possible, con~ sistcntly with the place it holds in his nosology, divides the miliary fever into two varieties, the idiopathic and symptomatic. The former, he confesses, he mentions, not from his own observations, but those of foreign writers. All the cases of miliary fever whkh he himself saw, he refers to the latter variety 4 * Some authors eved assert that the miliary fever is most apt to attack those win have formerly laboured under it. See Vogel de Cog. et Cur. Morb.—I know a woman who is subjectto this eruption in almost every indisposition under which she labours. t See Cullen's Synop. Nos. Meth. genus "2. X It is when the miliar^ eruption is of that kind which has been caUed the w.ute miliary eruption, that the convent is supposed to have the best claim to be considered an Exanthema; but its claim seems no better tounued than that in *hich the red miliary eruption (the rash as it is call- ed in Inland) appears; beta kinds of eruption frequently appear on the same pauent at the same time. n ia INTRODUCTION. 13 But I have found no facts in the writings of any foreign author I have met with, who treats of the miliary fever, capable of war- ranting this division, or of setting aside Dr. Cullen's mode of reasoning with respect to any of the cases of which they give an account.* The miliary eruption has doubtless now and then attended the raging fever; but so have Petechia. A variety of circumstances, improper treatment for instance, (and we have reason to believe that this is the circumstance which has most frequently operated) may render the inhabitants of any particular neighbourhood sub- ject to the miliary eruption, while labouring under fever. Can we suppose any thing peculiar in the fever produced by a fractured limb ? Yet Burserius mentions a case of this kind attended by the miliary eruption. In what fever does it appear so frequently as in the Puerperal, between which and the Exanthemata there is surely very little analogy ? This eruption in short appears in all febrile diseases, when its peculiar causes happen to have been applied. It appears in the Exanthemata, the Phlegmasia?, the Ifxmorrhagix, and Profluvia, as well as in fevers properly so called ; nay, its appearance we shall find is not even confined to febrile diseases. It seems to be nothing more than an accidental symptom, which is most apt to occur in fever, but may appear in any disease whatever. And, like Petechia?, it also sometimes appears unaccompanied by any other complaint, t * The principal foreign authors I allude to are Hoffman in his Opera .Physico-Medica, Van Swieten in his Comment, in Aph. Boerhavii, Lieu- taud in his Synopsis Praxeos Medicinx, de Haen in his Ratio Medendi, Burserius in his Institutiones Medicinx Practicx, Vogel in his work de Cog. et Cur. Morb., Quarin in his excellent work de Febribus, Allionius in his treatise dc Miliarium Origine, and Planchon in his work de la Fie- vre Miliaire. The following works also, Welsch de Novo Pueper. Morbo, Fantonns de Febre Miliare, Fischer de Febre Miliare, Gastallier sur la Fievre Miliare des Femmes en Couche, have found their way to this country, but I have not been able to meet with them. I was the less anx- ious to procure these treatises, as I found, after perusing what is said of the miliary fever by a few of die auffiors just mentioned^ there was little to !e met with in the works of others but a repetition of the same obser- vations. It must always happen that after six or eight autliors, who have been conversant with a disease, have given a copious account of it, many important facts relating to it will not remain to be mendoned by others. It instead ot facts, we are in quest of opinions, everv publication indeed presents us widi novelty enough. But of all knowledge, Uiat of medical hypotheses is the most useless, not to say hurtful. Neman, although he could without pains procure this knowledge, would have his memorybur- dened with it. With the hypotheses of some eminent writers indeed we hnd it necessary to be acquainted ; not that they are in general better founded than more obscure opinions, but because the authority of a great name has infused them extensively into the writings of succeeding authors. It will therefore be necessary, in the present work, to take an opportu- nity of giving a short account of the hypothesis of a Boerhaave, a Cullen or a Brown. ' t For cases ef the miliary eruption unattended by any other complaint, see Huxham on Fevers, White on die Diseases of Lying-in Women, Vol. I. E It INTRODUCTION. There are nearly the same reasons for rejecting the Aphthous^ as the miliary fever, from the number ofthe Exanthemata. " I « doubt, (savs Dr. Cullen) whether or not the Aphthae ouK'ht to " be arranged under the Exanthemata. Most cases .of Aphthae "which I have seen (he observes) appeared without fever; and " if at any time a fever did attend the Aphthae infantum, the for- " mer generally supervened upon the latter. A fever indeed (he " continues) does accompany the Aphthae of adults, but this fever « is of no particular kind, and the Aphthae generally appear to- " wards its termination ; nor as far as I know is there any fever " weil denned, or even mentioned by medical writers, which con- " stantly attends Aphthae." The Aphthae infantum is an idiopathic affection, and this form ofthe complaint has sometimes appeared in adults.* Cut a dis- ease unattended by fever does not certainly belong to the order of Exanthemata. We have to consider how far those cases in which Aphthx appear in fever deserve a place in this order. I have just quoted Dr. Cullen's observation, that Aphthx do not appear in a fever distinguished by any particular symptoms, as the eruptions in the Exanthemata are observed to do.f They appear in all kinds of fevers, in the symptomatic, as well as the idiopathic. In many of the former indeed they are more com- mon than in the latter. Sydenham declares, that there is no complaint in which he found Aphthx so common as in dysentery, and in those fevers on which dysentery had supervened. We know that tins affection is one ofthe most common forerunners of death in Phthisis, &c. With what propriety then are Aphthae ranked among the Exanthemata ? We shall even find, when we come to consider them more particularly, that Aphthx, when at- tended by common continued fever, (the only case in which there can be a shadow of reason for regarding them as an Exanthema) can generally be traced to causes different from those which pro- duce the fever in which they occur; very frequently to affection* of the primx vix, or suppressed sweats. Bi.rserius's Institntiones Medicinx Practicx. Even Hoffman observes, that the red miliary eruption is often chronic, continuing a considerable time without fever, and often returning at certain seasons of the year. The white is more rarely unaccompanied with fe-.er. * Cases of this kind are mentioned by Boerhaave, by Ketelacr in his Treatise de Aphthis nostratibus, Arncman in his Commentatio de Aph- this, and others. Such cases however are extremely rare. Van Swieten lived for many years m a country where Aphthx were very common vet he never saw a case of Aphthx in an adult not labouring under fever : and Dr. Cullen makes the same observation with respect to his own ex- perience. t Certain symptoms indeed generally precede all eruptions; but in the cases we are at present considering, the attending svmpVr. s appear oc- casionally m all kinds of levers, and at all periods of them. Whereas in kM? SySTK' *efever fr°m ^s commencement is cfa £X£ kind, at least attended with peculiar symptoms. INTRODUCTION. 35 Dr. Cullen has also expressed his doubts respecting the pro- priety of ranking the Erysipelas among the Exanthemata ; and regards the species which have been termed Erysipelas pestilens and Frysipelas contagiosum, as nothing more than Typhus attend- ed by an Lrythematic inflammation. All the arguments urged for the exclusion of the miliary fever from the Exanthemata, are equally strong when applied to the Erysipelas : it is not a contagious disease ; the eruption often ap- pears indeed,- like those just mentioned, in contagious fevers, but it is not necessarily communicated along with such fevers. Like the miliary eruption, it appears in various kinds of fevers, in the symptomatic as well as idiopathic. External warmth and irritation are capable of producing the Erysipelas in the pre- disposed, as well as the miliary eruption. There is no par- ticular period ofthe fever at which the Erysipelas shews itself; and with regard to its recurrence, it is even most apt to attack those who have formerly laboured under it. We shall afterwards find, that there is another complaint, in which the same kind of inflammation appears as in the Erysipe- las, termed by Sauvages and Cullen (for other authors have used the word in a very indefinite sense) Erythema. The difference between the Erysipelas and Erythema is, that in the former, the inflammation supervenes on a fever; in the latter, the inflamma- tion is the primary affection, and the fever merely its conse- quence. The Erysipelas seems to be nothing more than an Ery- thema, supervening on any kind of continued fever ; and as such I shall consider it along with the other eruptions which appear in these fevers.* * I have arranged the Erysipelatous fever among the varieties of Syn- ochus, because, like those just mentioned, it has been airanged among the Exanthemata; but if the view I have here taken of it be just, and that it is so will 1 think more fully appear when we come to speak of its treatment, it should have no place in a system of nosology, since it is a com- bination of a Phlegmasia and continued fever ; and it is of the combina- tions of symptoms, not of diseases, that nosology treats. It may be said indeed, that as all the eruptions we have been considering, occasionally appear unaccompanied by any other complaint, the - same objection holds against admitting the other varieties of Synochus into a nosological sys- tem. And this cannot be denied. But most of these eruptions appear so rarely as a distinct complaint, and their appearance in continued fever, or rather the causes which produce them, so modify many of its symp- toms withput altering the nature of the fever, as we shall find the appear- ance of tne Erythematic inflammation generally does, that it is useful in practice to regard those combinations as single diseases- The most me- diodical arrangement in a system of nosology is not always the most use- ful : for another proof of which I may refer to what was said of the dc- ■ fmitions of Synocha and Typhus, in which we introduce symptoms not essential to these complaints, in order to draw a line of distinction which nature has not made, because the division is useful in the practice in fe- vers, and still more so in teaching the principles of that practice. This is one of the circumstances I alluded to, when it was observed in the preface that a perfect system of nosology is not to be looked for. Al- though for, the reasons just given, I have arranged the Erysipelatous 5itted to attack the same person repeat- edly and there are many well authenticated instances on record ofthe small-pox and measles attacking the same person a second or third time £ SX^cTS1 Med-Prac-Rosen-ta HaUe'"a Dis^ INTRODUCTION. 3* The following then may be adopted as the definition of thel third order of Idiopathic fevers : Morbi contagiosi cum febre idio- pathica incipientes, definito tempore apparent Papulx, sxpe plures, exigux, per culem sparsx. Under this order are arranged the Variola, the Varicella, the Rubeola, the Scarlatina, the Pestis, and the Urticaria. Such is the mode of arrangement I shall adopt in treating of idiopathic fevers; on the arrangement of the symptomatic, a very few words will be sufficient. This class of diseases comprehends the three remaining orders of Dr. Cullen's Pyrexiae, viz. the se- cond, fourth, and fifth, the Phlegmasia, Hxmorrhagix, and Pro- fluvia ; and may be defined, Morbus localis, calore aucto, pulsu frequente. Dr. Cullen's definition of the first order of this class, the Phleg- masia, (the second order of his Pyrexiae) is, " Febris synocha, " phlogosis, vel dolor topicus simul lxsa partis internx functione, " sanguis missus et jam concretus superficiem coriaccam albam " ostenden*." This definition requires considerable alterations. I have al- ready given my reasons for rejecting the term Phlogosis. Ac- cording to the arrangement I have adopted, this definition must also be made to include that of the class of which it is an order; and I think there are several reasons for rejecting the latter part of it, namely, " Sanguis missus et jam concretus superficiem co- " riaccam albam ostendens." The appearance of the buffy coat on the blood does not, we shall find, uniformly indicate the pre- sence of inflammation y nor does it always attend inflammation. Besides, although its appearance did lead to a perfect knowledge of the nature of the disease, it should not enter into a nosological character, because we can only determine the presence of the complaint in this way after we have prescribed the remedies. But as the other parts of the character are not always, though generally, sufficient for distinguishing the complaints arranged under it, I would propose, instead of sanguis missus, Sec. to insert pulsus durus, which at least as constantly attends the Phlegmasia, as the buffy coat of the blood. Febris Synocha is also perhaps exceptionable, as we shall find that in certain spe- cies of Phlegmasia, the fever is a Typhus ; as, for example, in the Pneumonia Putrida of foreign authors, and the Cynanche Maligna. In the Gastritis and Lnteritis too, notwithstanding a degree of hardness in the pulse, the fever is certainly more of the nature of Typhus than of Synocha. There is an evident in- accuracy in admitting Synocha into the definition of an order, when we find it necessary in several of the genera of that order to call the fever Pyrexia typhodes.* Dr. Cullen's reason for ma» * See Dr. Cullen's definition of the Gastritis and Enteritis. \ 40 MTR0DUCTI0N. king Synochaa part of the definition of the Phlegmasia, is evi- dent, namely, because in a great majority of the Phk-rmasis, the fever is of this kind ; k pn%y he thought thcrclore ihc altera- tion I here propose is not for the better. I have al-e.uly more than once had occasion lo observe that our view is to form an use- ful, not a perfect, system of nosology.* But as t..r a« 1 can judge, the introduction of pulsus durus into the defiiulion an- swers every purpose which that of Synocha can serve, and it seems proper for other reasons that pulsus durus should make a p.'.rt of this definition. For these reasons I would propose the following definition of the Phlegmasix : Febres symptomatica, pulso duru ; quibus est pro morbo locali, vel inflammatio externa, vel dolor topicus simul Ixta partis interna funcione. Still supposing simple inflamma- tion to have been defined in the class Locales.t The Ilamorrhagia (the fourth order of Dr. Cullen's Pyrexia) form the second order of symptomatic fevers. They are defined by Dr. Cullen : " Pyrexia cum profusione sauguiniV''absque vi " externa ; sanguis missus ut in Phlegmasiis appai et. " Sanguis missus ut in Phlegmasiis apparpt," cannot here be objected to, for the same reason that " Sanguis missus et jam," tec. was omitted in the last definition. But as the buffy cdat is not always observed in Hemorrhagies, as its degree is regulated by a variety of accidental circumstances, and as the definition, without this addition, is sufficient to distinguish the diseases ar- ranged under it, it is better I think to omit it. It is also necessa- ry to alter the definition, in order to suit it to the general mode of arrangement I have, adopted. It may be expressed in the follow- ing manner, Febres symptomatica, quibus est pro morbo locali, sanguinis profusio absque vi externa. The Profluvia, the third and last order of symptomatic fcvfcrs, (which Dr. Cullen makes the last order of his Pyrexix) he de- fines, " Pyrexia cum excretione aucta naturaliter non san-~ " guinea."! This definition requires no farther alteration than the mode of arrangement I follow renders necessary ; Febres symptomatica, quibus est pro morbp locali, excretio aucta natu- raliter non sanguinea. Such is the mode of arrangement which I mean to adopt. It may be proper to present it to the reader at one view. * See the notes in die 43d and 44th pages of Dr. Cullen's Syn. Nos. Meth f Before entering on the consideration of the Phlegmasia, it will be necessary to make some observations on the simple inflam mauons. X Nftunjiter non sanguinea, is introduced into this definition, in order to exclude from the diseases arranged under it the Menorrhagia. W th what propriety this is ranked among the Hamorrhagia it isdifficult tn INTRODUCTION 41 ARRANGEMENT OF FEBRILE DISEASES*. CLASSIS I. FEBRES IDIOPATHIC^. Pragressis languore, lassitudine, et aliis debilitatiS signis, pul« sus frequens, calor auctus, sine morbo locali primario. ORDO I. FEBRES INTERMITTENTES ET REMLTTENTES. Febres idiopathica, paroxysmis pluribus apyrexia, saltern re* itiissione evidente, interposita, cum exacerbatione notabili, et plerumque cum horrore redeuntibus, constantes.* ORDO II. FEBRES CONTINUAL. Febres Idiopathica, sine intermissione, sed cum remissionibus et exacerbationibus, parum licet notabilibus, perstantes. SPECIES 1. SYNOCHA. Calor plurimum auctus, pulsus frequens, validus, et durus, urina rubra, sensorii functiones parum turbatae. SPECIES 2. TYPHUS. Morbus contagiosus, calor parum auctus, pulsus parvus, debilis, plerumque frequens, urina parum mutata, sensorii functiones plurimum turbatae, vires multum imminutae. * The species and varieties of these fevers are very numerous. It will be necessary to consider them in a separate chapter, I therefore say no- thing of them here. Vox. I. F 4* INTRODUCTION. SPECIES 3. SYNOCHUS. Morbus contagiosus, febris ex synocha et typho composita ^ initio synocha, progressu et versus finem, typhus. Varietas I ma. Synochus Sim/ilex. Varietas 2da. Synochus Pctcchialis* Varietas Stia. Synochus Miliaris. Varietas 4ta. Synochus Aphthosus. Varietas 5ta. Syntchus Erysipelatosus. Varittas 6ta. Synochus Vesicularis.* ORDO III. EXANTHEMATA. Morbi contagiosi, cum febre idiopathicaf incipientes; definite tempore, apparent papulae, saepe plures,. exiguae, per cutem, sparsae. SPECIES 1. VARIOLA. SPECIES 2. VARICELLA. SPECIES 3. RUBEOLA. SPECIES 4. SCARLATINA. SPECIES 5. PESTI3. SPECIES 6. urticaria: * The definitions of these varieties, and of the foUowise snecie* shall be considered when I come to treat of. them separately. t A single word would be preferable to the circumlocutions Febris Idi- S^FebnS S™tomatica> ** I wished to avoid S£fe INTRODUCTION. 41 CLASSIS II. FEBRES SYMPTOMATICA. TMorbi locales, calore aucto, pulsu frequente. ORDO J. PHLEGMASIA. * Febres symptomaticae, pulsu duro; quibus est pro morbo loca- li, vel inflammatio externa, vel dolor topicus simul lassa partis internae functione. SPECIES t. PHLOGOSIS. SPECIES 2. OPHTHALMIA, SPECIES 3. PHRENITIS. SPECIES 4. CYNANCHE. SPECIES 5. PNEUMONIA,. SPECIES 6. CARDITIS. SPECIES 7. PERITONITIS. SPECIES 8. GASTRITIS. SPECIES 9. ENTERITIS. SPECIES 10. HEPATITIS. SPECIES 11. SPLENITIS. SPECIES 12. NEPHRITIS. SPECIES IS. CYSTITIS. SPECIES 14. HYSTERITIS. SPECIES 15. RHE UMATISMUS. SPECIES 16. ODONTALGIA. 44 INTRODUCTION. SPECIES 17. PODAGRA. SPECIES 18. ANTHROPUOSIS. ORDO II. HMMORRHAGIJE, ■ Febres symptomatic ae, quibus est pro morbo locali, sanguinit profusio absque vi externa. SPECIES I. EPISTAXIS. SPECIES 2. HMMOPTYSIS. SPECIES 3. HJEMORRHOIS. SPECIES 4. MENORRHAGIA. SPECIES 5. HJEMATEMESIS. SPECIES 6. HAMATURIA.* ORDO III. PROFLUVIA. Febres symptomatica, quibus est pro morbo locali, excretio aucta naturaliter non sanguinea, SPECIES 1. CATARRHUS* SPECIES 2. DYSENTERIA.\ * The Hamatemesis and Hamaturia, regarded by Dr. Cullen as al- ways symptomatic, are sometimes, though rarely, idiopathic. I have seen the Hamaturia idiopathic.' The Cystirrhagia (liis last species of Hemorrhagy) is perhaps never idiopathic. ' m t At the end of the work we shall be enabled to take a more detailed View of diat part of a nosological system which relates to febrile leases when we shall have considered the definitions and varieties cl these complaints. PART I. OF IDIOPATHIC FEVERS. XDIOPATHIC fevers, it has been observed in the introduction, are distinguished by the following symptoms: Languor, lassi- tude, and other signs of debility, followed by a frequent pulse and increased heat, without any primary local affection. This class comprehends three orders, Intermitting and Remitting Feversj Continued Fevers, and the Exanthemata, or Eruptive Fevers. BOOK I. OF INTERMITTING AND REMITTING FEVERS. X1.CCORDING to the definition given in the introduction, in- termitting and remitting fevers consist of repeated paroxysms, returning with an evident exacerbation, and generally with shiver- ing, complete apyrexia, or at least an evident remission being interposed. I am now to consider the phenomena of these com- plaints more fully. CHAP. I. Of the Species and Varieties of Intermitting and Remitting Fevers. JlNTERMITTING and remitting fevers have long been divi- ded into Quotidians, Tertians, and Quartans, that is, fevers re- turning every day, every second day, and every third day. To which arc to be added, those whose paroxysms recur at a longer interval.* The revolution, intervaj, or period, as it is called, is divided into two parts, that during which the fever prevails, and that du- ring which it is absent or nearly so. The former, is termed the « paroxysm ; the latter, the intermission or apyrexia, if the fever ceases altogether ; it is termed the remission, if the symptoms only suffer an abatement, * The interval, it must b* remembered, is the space of time occupied by what is called a complete revolution or period of the fever, that is, the time from the accession of one fit to that of the next And when phy- sicians talk cf a Tertian, Quartan, &fc they count from the beginning "of a revolution. Thii% in a Tertian, the dr.y on which the fever appears is the first day; the next, the second; and the next, on which the fever afcain takes place, the diird; this fever diercfore is termed a Tertian. Si;;ne confusion cf names has arisen among the vulgar, from not attend- ing to this nude of reckoning. 46 INTERMITTING AND Hippocrates mentions intermittents which returned on the fifth, seventh, or eighth days. Boerhaave says he saw a Septe- nary, that is, a fever returning every seventh day ; and Van Swieten saw a Quartan change to a Quintan. Many similar ob- servations have been made. Burserius enumerates no less than twelve authors who saw a Quintan distinctly marked, nine who met with Septenaries, sixteen who met with Octans, several who met with fevers returning on the ninth, the tentli, and even the fourteenth or fifteenth day. We also read of fevers which are said to have returned once a month, once in two months, &c. These have been termed Menstruae, Bimenstrua, &c. and some authors even speak of fevers which returned yearly, termed Annua. How far the observations of those who mention fevers with such intervals are accurate, it is difficult to say ; on comparing them with the observations of others, we cannot help suspecting their accuracy. Galen, whose practice was more extensive per- haps than that of any other physician, never saw a fever with a longer interval than a Quintan, and very rarely this.f The par- ticular state of the weather at certain times of the year, by pro- ducing fever in the predisposed, often gives rise to the appear- ance of an annual intermittent. But the fever in such cases is always of the continued kind, and never assumes the appearance of the paroxysm of an Ague. Besides the Quotidian, Tertian, Quartan, and the fevers of more protracted periods, there are other intermittents and re- mittentsjj in which the return of the paroxysm is irregular, that is, whose revolutions are not performed in equal times. These are considered by Dr. Cullen, as varieties of the Tertian and Quartan.. They have been termed Erratica, Quintana, Septana, Octana, Nonana, Lunatica.|| Each intermittent has also been divided into Benigna, Maligna or Corruptiva, Primaria, Secondaria or Symptomatica, Periodi- ca ; Partialis, that is, affecting the body partially; Sporadica, appearing at the same time with other diseases ; Endemica, ap- pearing in a place which from its natural situation is peculiarly apt to produce the disease ; and Epidemica, prevailing generally at any particular season. Such divisions (as may be inferred irom the meaning of the terms) are quite useless. of th^TerUan^11^ ^ ^ MPectod *>? later writen to be a variety X {n the following pages what is said of intermittents (in order to shor- ten the> expression) isiimphed of remittents, except where SeanhS evidendy points out the contrary. * wucie uie meanuig U There are many fevers of this kind mentioned in the works «f Ft REMITTING FEVERS'. 47" intermittents have also been regarded as varying according as they are accompanied by certain symptoms, by coma for instance^ syncope, convulsions, an efflorescence on the skin, much sweat- ing, great inquietude, nausea, vomiting, delirium, Sec. hence the ttames Elodes, Assodes, Syncopalis, &c. This division also i4 quite useless. The same may be said of that division which regards intermit* tents, as varying according as they are accompanied with other complaints; Scurvy, Syphriis, Worms, Dysentery, Epilepsyf Gout, Sec. and of that which makes them vary according to the nature of the remote cause. We shall find, in considering the remote causes of intermittents, that there is very little room for any division of this kind. Of all the species of intermittents, it will be necessary to con- sider particularly only three. The others have not been accu-* rately observed, very rarely occur, and are suspected by many, and not without reason, to be only varieties of these. The intermittents which deserve a particular consideration are the Quotidian, Tertian, and Quartan. Of these, the most noted is the Tertian. It occurs most frequently ; so much so indeed, that Dr. Fordyce* and others are of opinion, that all fevers, whe- ther continued or intermitting, are varieties of this: an opinion not to be admitted however, as will be sufficiently evident, I think, after we shall have considered the symptoms and varieties of these complaints. SECT. I. Ofthe Varieties ofthe Tertian.^ THE Tertian is defined by Dr. Cullen, " Paroxysm! similes! « intervallo quadraginta octo circiter horarum, accessionibus me- ** ridianis." The Tertian, whose paroxysm does not exceed twelve hours*. is called the true simple Tertian; that whose paroxysm exceeds twelve hours, is called the spurious simple Tertian. The former, Dr. Cleghornf remarks, frequently comes on about the middle * See Dr. Fordyce's first Dissertation on Simple Fever. t In considering the varieties of intermittents, it is proper to begin with the Tertian, because its varieties have been better marked,, and are more numerous than those of the Quotidian and Quartan. However un- interesting this part of the subject is, die practitioner must be acquainted with it, since the varieties about to be pointed out are constantly occurring in practice; and it is necessary to know the meaning of terms employea- by the authors who treat of these fevers. % See Cleghorn's Treatise on the Diseases of Minorca* 43 INTERMITTING AND ofthe day, and goes off the same evening; the other comes ofJ much earlier, and often lasts for eighteen hours.* The Tertian varies in the frequency ofthe recurrence, as well as the length of its paroxysms ; instead of every second day, it somedmes returns everyday; it is thfcn distinguished from the Quotidian by its alternate paroxysms being similar, that is, by the paroxysms of the odd clays being similar, but more or less severe, hi all, or some of their stages, making their attack at an earlier or later time of the day, &c. than the paroxysms of the even days. When the paroxysms recur in this way, the lever is termed Tertiana duplex ; and there might be a division of the Tertiana duple? into that in which the most severe paroxysm happens on the even, and that in which it happens on the odd, day, counting from the beginning ofthe complaint. And this division is not so useless as at first sight it may appear ; it "assists, we shall find, in forming the prognosis, particularly in double Tertian re* mittents.t It has been ohserved that the most severe fit is fol- lowed by the most Complete apyrexia. Double Tertians, if the fit does not exceed twelve hours, arc termed true double Tertians; when it exceeds twelve hours, spurious double Tertians. When the fits are so protracted that one begins almost as soon as the preceding fit ends, this as well as other remittents have been termed subintrant, or sub-continued. Subintrant fevers are almost always remittents, complete apyrexia rarely taking place in them. The Tertian sometimes returns twice every second day, the intermediate day having no paroxysm; it is then termed Tertiana duplicata. It sometimes returns twice every second day, while one parox- ysm takes place on the intermediate day ; the fever is then termed Tertiana triplex. And Tulpius relates a case of the Tertiana quadruplex, which has escaped the observation of most authors, in which two paroxysms take place every day.l It is still to be remembered that the Tertian type is discovered by the parox- ysms being similar on alternate clays. When we come to con- sider the manner in which intermittents suffer a reduplication of their paroxysms, we shall find, that as often as an additional par- oxysm takes place in any of these fevers, both the new and the * Hippocrates observes, and the observation is confirmed by Voeel (see Vogel de Cog. et Cur. Morb.) and others, diat the paroxysmsof Ter- tians, as well as other intennitteius, are less frequently protracted when the patient is young, his general health good, and particularly when he is not troubled with visceral obstructions. t See Cleghorn on the Tertian, in his Treatise on the Diseases of Mmorca. • «^J JhA£asememi01^1 ry ™V{xiS suPervened on a double Tertian. SeelusObseirvauonesMedicx,!. iv. c.46. *ww«. REMITTING FEVERS. A9 original paroxysms are move protracted than the latter were be- fore the accession of the former. Considering this circumstance, and the frequency of the paroxysms in a quadruple Tertian, the f remissions must be extremely slight, and the complaint conse- quently must assume entirely, or in a great-measure, the appear- ance of a continued fever, according to the foregoing definition of this complaint. When a single paroxysm takes place every day, but the re- mission between the first and second paroxysm is more consider- able than that between the second and third, the remission between the third and fourth more considerable than between the fourth and fifth, and so on ;* the Tertian has been called Haemitritaus or Semitertiana. Different authors however do not always em- ploy these terms in the same sense.f The interval of the Tertian, it was observed, is forty-eight hours, but sometimes it is rather less, the fit coming on at an earlier time ofthe day ; and sometimes it is more, the fit coming on at a later time of the day than that which preceded. When the former happens, the fever is called an anticipating Tertian (Tertiana pravertens); when the latter happens, a postponing Tertian (Tertiana tafdans). And Dr. Cleghorn has observed of the double Tertian, that the more severe fit often comes on a lit- tle earlier in each period, while the slight fit returns at the same hour of the day, or perhaps later. • It is remarkable, that postponing agues, after the accession of ■ the paroxysm is postponed to eight o'clock in the evening, fre- quently have their next accession early iu the morning ofthe day following that on which the fever should have returned ; and \n like manner, after an anticipating paroxysm has occurred at eight o'clock in the morning, the next accession is often on the evening * This indeed is generally the case in double Tertians; but when it is more remarkable than usual, it has given rise to a particular division of . this fever. f The following account of the Ilamitritaus by Celsns, does not cor- respond to this cci.ijition. There are two kinds of Tertians, he observes the one coming en and terminating like the Quartan, with this only differ- ence, that between the paroxysms the patient remains well for only one day, the fever returning on the third, (this is the common simple Tertian w the other, he continues, is much more pernicious; ihis indeed, like the former, returns every third day, but oi ihe fortv-eight hours almost siv and thirty are occupied by the feier, and during the remainder the fever never wholly disappears, but only buffers an abatement of its symp- toms. " Id genus (he adds) plerique medici Hamitritacn appellant!" In this account of die Hamitritaus, Celsus wholly overlooks the remission which takes place, according to the abo\c definition, between die unequal and equal days, the first ard tecend, third and fourth, &c. The sense in which others ut-e the. term Hamitritaus differs still more Morb. sect. 4, p. 83. ' " Ccg' Ci Cwf" Vol. I. G so INTERMITTING AND of the day preceding that on which it should happen* A post' poning intermittent is a safer fever than an anticipating one. SECT. II. Of the Varieties of the Quartan and Quotidian. HAVING considered the varieties of the Tertian at some length, it will not be necessary to spend much time in consider- ing those ofthe Quartan and Quotidian. The former (the Quar- tan) is defined by Dr. Cullen, " Paroxysmi similes intervallo sep- " tuaginta duarum circiter horarum, accessionibus pomeridi- " anis." This, like the Tertian, varies in the length of its paroxysms, and the manner and frequency of their recurrence. There are sometimes two paroxysms every fourth day ; the fever is then called Quartiana duplicata. At other times there are three par- o:;;,:.ii]s every fourth day ; it is then called Quartiana triplicata. Sometimes, of the four days, the third only is without a parox- ysm ; a single paroxysm taking place on the first, second, and fourth days ; each paroxysm being similar to that which occurs on the fourth clay before it; the fever is then called Quartana duplex. The paroxysm returns sometimes every day ; the par- oxysms happening on every fourth day being similar; it is then called Quartana triplex. The following is Dr. .Cullen's definition of the Quotidhfh,. " Paroxysmi similes intervallo viginti quatuor circiter horarum,. " paroxysmis matutinis." This fever varies chiefly in the length of its paroxysms, and5 the degree of remission. Some Quotidians, Celsus observes, suffer so complete a remission, that the patient is free from the fever between the paroxysms. In others, though an abatement of the symptoms takes place, yet more or less'of the fever re- mains throughout the paroxysm. This is the only way in which Celsus regards the Quotidian as varying. According to Burse- nus, however, it varies also in having one, two, and evert three paroxysms m the day, and these varieties he terms the simple double, and triple Quotidian. But a Quotidian with the appear- ance of two or three paroxysms in the dav, (for they are never very distinctly marked) is not to be distinguished from a continued , * ThuV,fth,e Paroxvsm of an anticipating Tertian comes on at nin,» o clock on Monday nionnng, the neM paroxysm at eieht o'clock or*Wed nesday morning, the third iwroxvsm will nvnKoNi,r,!L 1„C.^ °J!Wed" o clock on Friday niornim manner, if a postponing' day evening, and the nej lay evening the third paroxysm will probably take Dlace nn > clock on Friday evening, but some tinfe on si^yteta™ «..«.m«. u a pobmoning leitian make its attack at seven o'clock onMnn • clock on Friday evening but some tin e ™ 4L~ilP'f ^ "ot at n,»e REMITTING FEVERS. 51 fever. The terms anticipating, postponing, subintrant, 8cc. ap- plied to the Quartan and Quotidian, are employed in the same sense as when applied to the Tertian. All these fevers, it may be observed, are said in the definitions to make their attack in the day time. The Quotidian in the morning, the Tertian at noon, and the Quartan in the afternoon. It is remarkable of all fevers, that nine perhaps out of ten make their attack between eight o'clock in the morning and eight in the evening The cause of this may be, that a state of natural sleep is opposite to that of fever. Such are the different species and varieties of intermitting fevers. Before we leave this part of the subject^ it may seem proper to consider the manner in which the different types* as- sume more or less ofthe continued form ; but it will be better to defer this till we shall have considered the symptoms of these fevers. CHAP. II. Of the Symptoms of Intermitting and Remitting Fevers. JLN treating of the symptoms of intermitting and remitting fe- vers, I shall in the first section give a detail of the symptoms which more properly belong to these fevers. In the second, I shall give the reader a view of what may be termed the anoma- lous symptoms of intermittents. In the third section, I shall point out the diseases with which these fevers arc most frequently complicated. In the fourth, we shall consider more particularly the prognosis in intermittents. In the fifth, take a view of the symptoms which characterise the different types. And in the last, consider the manner in which these assume more or less of the continued form. These heads, with what has been said, comprehend all that re- lates to the symptoms of intermittents, except what may be said of their crises. The term crisis has not been used in a very de- finite sense ; I shall generally employ it to express certain symp- toms which are often observed to attend the change from fever to health. As it will be proper to throw together the observa- tions which it is necessary to make on the crises of fevers ; and as the crisis which in intermittents is almost always the same, is, in continued fevers, very various, I shall defer the consideration of this part of the subject till I come to speak of the latter set of complaints. I am in the first place then to lay before the reader the symptoms of intermittents in general. * By type is meant the species of the intermittent. All Quotidians are -of the same type ; Quotidians and Tertians are of different types. w INTERMITTING AND SECT. I. Ofthe Symptoms of Intermitting and Remitting Fevers. A short account of intermitting and remitting fevers has al- ready been given. We arc told, in the definition of those diseases, that they are fevers consisting of repeated paroxysms, complete apyrexia, or at least an evident remission, being interposed. It is necessary however to take a more particular view of their symp- toms. A regular fit or paroxysm of an intermittent is divided into three stages. The most striking symptoms of the first stage are, a sense of cold and shaking; this is therefore termed the cold stage. The second is characterised by an increase of tempera- ture ; it is therefore called the hot stage ; and the chief symptom of the last, which is termed the sweating stag*e, is a copious secretion by the skin. 1. Of the Symptoms nf the Cold Stage of Intermittents.* At the commencement of the fit the patient is more indolent than usual, frequently yawning and stretching himself. The aversion'to motion increases till it arrives at an uneasy weariness over the whole body ; and sometimes the weakness is such, that he is scarcely able to support himself. He is restless, soon tired ofthe same posture, yet feels an uneasy exertion in changing it. His thoughts succeed each other more rapidly than usual, and he feels it irksome to bend his attention for a considerable time to one object. The pulfe is now weaker and sometimes slower an natural. At the commencement of these symptoms the patient does not always complain of cold, but his skin, especially in the extremi- ties, often feels cold to another person. The nails soon begin to grow pale, the same gradually happens to the fingers, toes, lips, 8cc. and the skin becomes rough as when exposed to cold, and less sensible than usual. The patient now complains of a sense of cold, which indeed sometimes from the first attends the foregoing symptoms. After this, which on its first coming on is generally referred to the * That the following account cf the symptoms of intermittents may be less complicated, I have omitted manv which will be mentioned under the head Prognosis, and shall here give those which may be regarded as more properly constituting the disease. It is necessary to have recourse to tin-,, or some other such means when the symptoms of di^ea^s are very numerous, m order to avoid confusion; which is not to be done when the reader is at once presented with a great variety of symptoms'. \ . e have sufficient proof cf this n the manner in which the symntoirs cf diseases are generally laid down by f,rc-n systematic writers, I ieuta.ud, REMITTING FEVERS. 52 back, has continued for a short time, a trembling begins in the" lower jaw, and gradually spreads over the whole body.* In some cases the sense of cold is partial, being confined to one or more of the limbs; while at the same time the rest of the body perhaps glows with heat; and while the cold is severe on the surface, a burning heat is sometimes felt internally. For a short time after the shaking begins, the skin continues cold to the feeling of another person, and measured by the ther- mometer is found considerably below the natural temperature. Its temperature has been observed as low as 74°. After the sha- king has lasted for some time, however, the patient still complain- ing of cold, the warmth of his skin to the feeling of another per- son, or measured by the thermometer, gradually increases. The pulse during the cold stage, is small, frequent, sometimes irregular, and often hardly to be felt; the respiration is also considerably affected. It is frequent and anxious, accompanied with a cough, or interrupted by sighing ; there is a sense of weight and often tightness and oppression about the pracordia, and that dejection of spirits which constantly attends these symp- toms. This is not the only change which takes place in the mind. The remembrance of things at other times desirable now disgusts ; and the hurry of thought which attended from the beginning ofthe paroxysm increasing, a degree of confusion takes place. If these symptoms continue to increase, they rise to delirium ; or more frequently the patient becomes stupid and a considerable degree of coma, or what has been termed the febrile apoplexy, supervenes. Delirium is a more frequent attendant on the hot stage, and coma on the cold ; the latter often appearing almost at the very commencement ofthe paroxysm. Although neither delirium nor coma attend the cold fit, it is not uncommon at this period of the disease for some of the senses to be considerably impaired ; the patient often complains of numb- ness in the limbs; and in some instances bolh sight and hearing have been almost lost. When this happens, the stomach is gen- erally loaded with bile.f *The teeth strike against each other, often with such force, that in- stances are on record ot the teeth of old people being knocked out by the (old fit of a Quartan. The trembling o\er the whole body indeed is some- times so severe, that after the cold fit the patient has hardly strength to move his limbs. Even syncope is ape to occur during this stage when the strength has been much reduced ; and it seldom occurs repeatedly with- out endangering life. In u-ry severe and long continued cold fits, partic- ularly in old people, the body has been known to become stiff almost like that cf a dead person. f We know that the stomach is oppressed, v\l m there is a bitter taste in the mouth, when the breath is fetid, the tongue yellowish and covered with thick mucus, when the padent is troubled with eructations, anxiety, 54 INTERMITTING AND Pains of the back, limbs, and loins, generally attend the coM stage, or the patient complains of a sensation as if the body had been bruised. There is, especially soon after the beginning of this stage, a shrinking of the extemities, so that a ring at other times tight, drops ofl* the finger. Ulcers often dry up, during the cold stage of agues; and tumors subside.* The natural functions are much deranged. At the beginning of the paroxysm the appetite ceases, and as the cold stage advances nausea frequently occurs, often succeeded by a vomiting of bile, which, in the intermittents, and still more in the remittents of sultry climates, and even ofthe warmer seasons of temperate cli- mates, is sometimes poured into the stomach and intestines in prodigious quantity. Less frequently the matter rejected by vom- iting, is a ropy, transparent fluid, nearly insipid ; often secreted in no less quantity in vai'ious kinds, or rather, in many cases of all kinds of fevers. When the quantity of bile in the stomach and intestines is ve- ry great, it is frequently (particularly towards the beginning of the hot fit) passed by stool as well as vomiting ; bile indeed of- ten predominates so much in these fevers, that the patient looks like a person in the jaundice, and the serum of the blood and the urine are tinged with yellow. With these symptoms the thirst is constant, the mouth and fau- ces dry and clammy. The urine, if not tinged with bile, is in the cold stage almost colourless and without cloud or sediment; and, if there be no bile" in the prima via, stools are uncommon at this period. Such are the symptoms of the cold stage of an intermittent. It must be recollected, however, that in different cases there is great variety ; we are not to expect that these symptoms will be equally remarkable in every patient, or that all of them will be observed in any one. Even the leading symptoms, the sense of cold, shaking, &c. are sometimes absent, so that we can hard- ly say there is any cold stage at all.f This however rarely hap- pens. r and a sense of oppression, pain or heat about die stomach, nausea, vomit- ing, heaviness or pain ofthe head, vertigo, thirst, and spontaneous dianrhcea. When these, or part ol these, symptoms are present to a con- siderable degree, they iorm one of those useless divisions of intermitting fever above alluded to, termed Intermittens Gastrica. See a copious ac- count of this species of intermittent, in the first volume of Frank's excel- lent work, entitled Epitome de Cur. Morb. * During the hot stage, or after the paroxysm is over, tumors reneral- ^e^arexysm. " "*' and ulcers aSain Charge matter a°s befor r Seethe section of the anomalous symptoms of intermittents. e REMITTING FEVERS. 55 The duration of the cold fit varies much ; sometimes it contin- ues four or five hours, or more, particularly in the intermittents of long periods; at other times it does not last above half an hour, or even a shorter time, particularly in remittents, and especially those approaching to die continued form. Its mean duration per- haps is between one and two hours.* During the first paroxysms, the cold stage is often longer than at a later period, becoming shorter as the disease increases in vi- olence, and particularly, as it suffers a prolongation and redupli- cation of its paroxysms ; till, at length, when the paroxysms have been so protracted as almost to run into each other, the cold fit is sometimes hardly perceivable. This part of the subject will be considered more particularly when speaking of the man- ner in which the different types assume more or less of the con- tinued form. 3. Of the Symptoms of the Hot and Sweating Stages. The hot stage succeeds the cold. It is sometimes ushered in by the vomiting which follows the nausea in the first stage ; or the cold and shivering, after alternating for some time with short fits of heat, gradually abate, and more permanent heat is at length diffused over every part of the body. The paleness and shrinking, together with the peculiar constriction of the skin which attend the cold stage, now disappear, and are succeeded by a general redness and fulness, which however give the appear- ance rather of turgescence than relaxation, the skin still remain- ing parched. The heat in this stage often raises Farenheit's thermometer five, six, or more degrees above the natural temperature. Dr. Fordyce states 105 Q as the greatest degree of febrile heat which he has observed. Other writers mention higher degrees. As the hot stage advances, other changes take place in the state of the vital functions. The pulse from being small, weak, and often irregular, becomes regular, strong, and full. And this state of the pulse generally increases till the sweat breaks out. The breathing, from being hurried, interrupted, and anxious, becomes more full and free, while the sense of tightness across the breast is in some measure relieved. In most cases, however, the breathing still continues more frequent and anxbus than in health. With regard to the animal functions; the sensibility which h* impaired in the cold stage, is morbidly increased in the hot. The patient cannot endure the least noise ; and the light is offen- sive. The pains of the limbs continue during the hot stage ; and the pain of the head, which is often wholly absent in the cold fit, now comes on or increases, frequently accompanied with a throb- * See M'Bride's Introduction to die Theory and Practice of Medicine. 6* INTERMITTING AND bing of the temporal arteries and tinnitus aurium The confu- sion of thought is upon the whole greater in this than in the for- mer stage, and more frequently rises to delirium.* The state of the natural functions suffers but little change. As the bot stage advances the nausea and vomiting abate, but the thirst still remains or increases. The urine,from being limpid, often becomes high coloured, but is still without sediment ; in other respects the slate of these functions is nearly the same as in the cold fit. Except when a diarrhoea accompanies the com- plaint, stools seldom occur till the end of the paroxysm, and then a general relaxation of the excrctorics taking place, there is usu- ally a loose stool. It is in the hot stage that hemorrhagies most frequently occur, at least those hemorrhagies which relieve the symptoms. They happen from various parts of the body ; from the uterus; from tiic rectum, if the patient happens to labour under the hamOrr- hoids ; sometimes from the lungs ; from the ears ; but most generally from the nose. If the hemorrhagy from the nose be free, it is almost always a favourable symptom, and sometimes brings immediate relief; but a few drops of blood falling from it, Cleghorn says, he generally found to portend danger, and others have made the same observation. The hemorrhagies which appear about the commencement of the hot stage, however, it may be observed, are generally the consequence of too rapid a circulation ; and if not favourable, arc seldom to be regarded as affording a bad prognosis. When we come to consider the Symptoms of typhus I shall have occasion to take notice of another species of hemorrhagies, which seldom attend the fevers I am speaking of, till, in consequence of a de- bilitated state of the system, they have nearly assumed the con- tinued form, and which almost always afford a bad prognosis. It is to be observed, that the appearance of hemorrhagies only assists us in judging of the event, when we attend to the symp- toms which accompany them, and the parts of the body from which the blood flows. They may afford the most favourable, or the most fatal prognosis. They will be considered more particu- larly among the crises of fever. It may be remarked at present, that when the excitement is considerable, they frequently prove favourable, and seldom do harm ; when the excitement is too low, they are rarely beneficial, and often followed by the worst consequences. * It is not uncommon at this period forthe patient to complainof nain ^dbo^^'tSs^hS? »•-» withaBeieof pulsation**52sC nines indicates inflammation, in the prima via!:. S ' Amlsomar REMITTING FEVERS. 57 When the fever has lasted for a considerable time, and the re- missions have become less complete, especially when the epi- demic is of a malignant nature ; a variety of symptoms denoting great debility, and affording a very unfavourable prognosis, shew themselves. But these, like the worst species of hemorrhagies, belong rather to continued, than intermitting, fevers. I shall have occasion to speak of them at large, when we come to consid- er the symptoms of typhus, the fever in which they most gene- rally make their appearance. It is sufficient here to have obser- ved, that the symptoms alluded to sometimes, though rarely, oc- cur, while the remissions are still very evident. "The violence of the hot stage is not, at all times, proportioned to that of the preceding cold fit. Dr. Cleghorn informs us, that the most violent fevers he ever saw came on without any cold stage. It is often observed, however, that the longer the cold stage is, the more violent is the succeeding hot fit, the type of the fever being the same. We shall find that, with respect to intermittents of different types, this is by no means the case, but rather the contrary. The hot stage is at length terminated by a profuse sweat, which forms the last stage of the paroxysm ; and soon relieves the patient. The sweating generally begins about the head and breast, extending gradually to the back and extremities. The strength and frequency of the pulse are now diminished, and the breathing becomes free. The urine deposits a sediment like brickdust, which has been termed lateritious; or a copious red- dish or white sediment, which writers have confounded with the other ;* and the patient generally falls into a sleep, while the symptoms of the fever abate, leaving him weak and wearied. If the fever be an intermittent, complete apyrexia succeeds. If a remittent, the symptoms of the hot stage, but with an evident abatement, continue till the recurrence of the paroxysm, which is regulated by the type of the fever, as has been shewn. Although the patient, between the paroxysms of an intermittent, Is free from fever, yet he seldom finds himself in perfect health, especially if the paroxysms have been severe. He is easily fa- tigued, complains of want of appetite, the skin is parched, or he is more liable to sweat than in health. Sometimes he is subject to vomiting or purging, and is often dejected and drowsy. The more the patient is harrassed by such symptoms during the apy- rexia, the more reason there is to dread that the ensuing parox- ysm will be severe. Such are the phenomena of intermitting fevers in general; they vary much in the violence and duration of the paroxysm, and in the proportional violence and duration of the different * It will be necessaiy to make some observations on these depositions from the urine, when I speak of the crises of fevers. Vol. I. H ss INTERMITTING AND stages constituting the paroxysm, as well as in the degree and length of the remissions, and the general health of the patient during them. All intermittents arc apt to change to a more or less continued form, the tendency to become continued is always unfavourable ; the prognosis is good when they change from a less to a more intermitting form. SECT. II. Of the Anomalous Symptoms of Intermittents. THERE is another class of symptoms belonging to intermit- tents in general. These may be termed anomalous, a great variety of which have been observed. The anomalous appearances belonging to intermittents, may be divided into four classes. The first, comprehending those cases in which the order of the different stages constituting a paroxysm is deranged, or in which some of these stages are wholly wanting. The second comprehending those cases in TThich the whole paroxysm or some of its stages are confined to particular parts of the body. The third, those in which certain symptoms prew.il so much as to alter considerably the appear- ance qf the disease. And the last, those in which other diseases or particular symptoms assume the form of an intermittent. Without giving a particular account of such cases, I shall refer to different works where the reader will find a variety of them falling under each of these heads. In the first place, of those in which the order of the stages is deranged or some of them wholly wanting. It is observed, by Cleghorn,* Senac,t and others, that the cold stage is sometimes wanting. Sometimes it accompa^ mes only some of the paroxysms: intermittents have blen observed to recur without the shivering for several of the firs" paroxysms. Frank* remarks, that even the hot stage itself is sometimes scarcely perceptible; at other times, as in cases ?S hn^?/ SenaC'",the ho; and -weating stages occur togethei 1 he hot nt docs not always follow the cold ; F?ank observes that the former sometimes precedes the latter: nor doe °thTsweat nc always follow the hot; the skin sometimes remaining Wectlv dry during the whole paroxysm.* « The tumult SS * See Cleghorn on the Diseases of Minorca. t See Senac de Febribus. t See Frank's Epitome de Cur. Morb. II De Febribus. % See Senac de Febribus. REMITTING FEVERS. 59 * (says Dr. Jackson,*) of intermittent fever, which terminate in *' most cases by sweat, went off'in some by urine or stool, or per- " haps declined in others without the appearance of any preter- «' natural.evacuation." Dr. Cleghorn also observes, that tertians sometimes terminate by urine or stool, rather than by sweat. And there are cases mentioned in the works of Burseriusf and Schenkius,* in which the order of the stages was so far inverted, that, in one instance, tlie cold stage was the last ofthe paroxysms, and in another, the sweating stage was the first. The second class ofthe anomalous cases of intermittents com- prehends those in which the paroxysm, or some of its stages, is confined to particular parts of the body. Vogcl|| observes, that the cold sometimes.seizes on one member only, for instance the arm, and is sometimes confined to one half of the head. This is a less uncommon occurence; but it is remarkable, that the whole fit should sometimes be confined to a particular part ofthe body, that a particular member should be seized with the symp- toms of the cold, hot, and sweating stages, while the rest of the body remains unaffected.§ The third class of anomalous cgses of intermittents compre- hends those in which certain symptoms prevail so much, as to al- ter considerably the appearance of the disease. , " Sometimes one or two symptoms of the fit (Dr. Cleg-horn*!! « observes) predominate with such violence'that the rest areob- " scured or altogether eclipsed. Hence we so frequently meet " with hemicranias, choleras, dysenteries, and chincough, re- " turning regularly at stated periods 4 and several fevers of " this class, upon account of some predominant symptom, have " had particular names bestowed on them." I formerly had oc- casion to mention these, which indeed are of no use ; it is neces-, sary however to be acquainted with them, since they are used by authors. Tertians, Dr. Cleghorn observes in another place, are sometimes so complicated with pains of the head, breast, belly, back or limbs, as to appear like a pleurisy, phrenzy, hepatitis, lumbago or rheumatism, particularly when the remissions are obscure. I have known patients, says Stork,** who along with fever were every day, at a certain time, seized with palpitation ofthe heart, * See Jackson on the Fevers of Jamaica. f See Burserius Institiit. Med. Pract.' X See Schenkius Observat. Med. Rariores. || See Vogel's Pralect. AcauVde Cog. et Cur. Morb. § There is a striking instance of tliis kind related in the*Nosologia Me- tnodica ot Sauvagcs. • 11 Diseases of Minorca. * * Sec Stork's Anni Medici, w INTERMITTING AND oi\gi cat anxiety about the pracocdia, with fruitless and violent coughing ; others were attacked with a violent pain ofthe whole, or part of the head. Sir John Pringle* observes, that among the intermittents which prevailed in the army in marshy countries, there were some which attacked the head so suddenly, and with such violence, that the men without any previous symptom of in- disposition ran about in a wild manner, and were believed to be mad till the solution of the disease, and its periodical return, shewed its real nature. Dr. Rush,t and many others, mention cases of intermit- tents coming on with delirium, particularly Mr. Clark in the fourth vplume of the Medical Observations and Inquiries. Great swelling of the tongue, a strangury, dreadful horror, with a de-» sire to die, and boils on the skin, mentioned as frequent symp-. toms in the bilious remittent fever of Bussarah, may also be re- garded as anomalous.:}: In the sixth volume of the Edinburgh Medical Essays there is a case related by Mr. Bain, in which epi- lepsy attended the paroxysms of an intermittent; and in the fif- teenth volume of the Medical Commentaries, another related by Mr. Davidson in which the paroxysms were accompanied by amaurosis. In short, the anomalous appearances of intermittents belong- ing to this class are very various. It is impossible to enumerate all that have been observed ; those just mentioned are sufficient to put the practitioner on his guard, and prevent embarrassment when such cases occur. It appears from the observations of a variety of authors, that when we succeed in removing the fever by the ordinary means, such anomalous symptoms yield along with it. This even happened in the two cases just alluded to, in which epilepsy and amaurosis were complicated with the inter- , mittent. It is to be observed, that when such violent symptoms occur, they often derange the fever, so that it is impossible to say of what type it is, But when the symptoms become more moderate, it generally assumes the same type which it had before the ac- cession of such symptoms. And what tends still farther to per- plex intermittents, and render them irregular, though indeed it rarely happens, is, that in one paroxysm certain symptoms shall predominate, and in another, symptoms of quite a different na- ture. The last class of anomalous cases, which may be regarded as belonging to the fevers we are speaking of, comprehends those in * See Sir John Pringle's Observations qn the Diseases ef the army. t See Rush's Medical Obs. and lnq. ^*Trhereis-a g0?d account cf mis dreadful fever in a work entitled REMITTING FEVERS. 61 which other diseases, or particular symptoms assume the form of an intermittent. Certain symptoms, such as pain in some part of the head, co- ma, delirium, even hiccup, recurring for several paroxysms, with intermitting fever, at length take place, at stated intervals, after every symptom of fever is removed. Cases of this kind are related by Senac and a variety of other authors. But it does not always happen that the symptoms which thus recur periodi- cally have accompanied an intermittent. They sometimes ap- pear from the first without fever, and continue to recur at the quotidian, tertian, or quartan interval. Stork* relates a case of amaurosis which recurred in this way. Rheumatic pains have often been observed to do so. Dr. Rusht relates several cases of this kind. There is a very curious account of pulmonary complaints assuming the form of an inter- mittent, by Dr. Chapman, in the first volume of the Medical Commentaries. Dr. Strack| enumerates many ofthe anomalous symptoms belonging to this class. He relates one case which never appeared in any other form but that of coma. He also met with inflammation of the eyes appearing as an intermittent, and enumerates pleuritis, cholera, cholic, gout, histeria, and convul- sions, 'as apt to assume the same form. Of all such cases it is remarkable, and deserves particular at- tention, that they almost always yield to the same means which remove intermittents, however dissimilar to these fevers they may be in all respects, except in their periodical recurrence. This curious fact has been established by very extensive obser- vation. I shall only add, before I leave the anomalous symptoms of intermittents, that they have sometimes left behind them irreg- ular shakings, which often prove very obstinate. There are ca- ses of this kind related by Dr. Monro in the second volume of the Edinb. Med. Ess. and Obs. and in the fourth volume of the same work by Mr. Andrew Willison. The case related by the latter yielded to the cold bath. SECT. III. Of tlie Diseases with which Intermittents are most frequently com- plicated. With regard to a variety of symptoms which often appear in intermittents, arising from their being complicated with other diseases, little can be said here, as I am not at present to treat of * See his Anni. Medici. | See his Med. Obs. and Inq. X Strack de Feb. Intermit. 62 INTERMITTING AND tffe different complaints to which they belong. The diseases with which they arc most frequently complicated are, diarrhoea* cholera, dysentery, obstructions of the difleient viscera, dropsy, jaundice, and different species of inflammation. Inflammation of some of the viscera and remittent fever is one of the most common of these combinations. De Haen* and others relate many cases of remittents, in which the stomach and bowels were found on dissection inflamed and sphacelated. This combination has been observed to be remarkably frequent in certain epidemics. Bartholinef in particular gives an account of an irregular remittent that raged at Copenhagen, which was always accompanied with inflammation of the stomach and duo- denum ; and we have an account of a similar fever which raged at Leyden, by Professor Silvius de la Boe.J The brain is also frequently the seat of inflammation in remittents, as appears from the account of dissections by Sir John Pringle|J and others ; and rheumatism, another inflammatory affection frequently ac- companies the intermittents of cold climates.§ The vernal intermittents are most commonly accompanied with inflammatory affections. In autumn these fevers are more frequently combined with the disorders that have been termed putrescent, particularly dysentery. , The frequent concurrence of some of the above-mentioned complaints and intermittents is owing to something peculiar in particular epidemics, or in the climates or constitutions in which intermittents generally occur ; but some of them are the effects of the fever itself: schirrous indurations of the viscera, for in- stance, and their consequences, jaundice and dropsy. The liver and spleen are the viscera most frequently affected. When we recollect the nature of the circulation in the liver, and consider whence the greater part of its blood is supplied, we are at no loss to account for the ascites that sometimes attends its induration. Nor is it difficult to conceive in what manner an induration and enlargement either of this viscous or the spleen frequently produce an anasarca of the inferior extremities, gra- dually extending over the whole body, when we reflect that the cava ascendens is exposed to the pressure of the enlarged visce- ra. That jaundice must frequently be the consequence of an induration of the liver or pancreas, (for this viscus is also some- times indurated in those who have suffered much from agues) is also evident from considering the situation of the biliary ducts, * See his Ratio Medendi. | Barthol. Hist. Anatom. Rar. hist. 56. X Prax. Med. Append, tract x. n See his observations on the diseases of the army. $ See the epidemics described by Sir John Pringle, in his Observ on the Du. of the Army. REMITTING FEVERS-. 6$ which may be pressed upon by enlarged portions of either of these organs. To these consequences of intermittent fever may be added ca- chexy and atrophy, a bad habit of body, and wasting from ob- structions of the mesenteric, pancreatic, and other glands of the abdomen. Agues also sometimes check habitual discharges, the menstrual and hemorrhoidal flux, and sometimes interrupt the secretion of milk in nurses. They also now and then occasion excessive discharges by sweat or stool, of the menses, lochia, If intermittents sometimes induce, they also now and then remove, other complaints. It has long been the opinion of phy- sicians, that intermittent fevers, if not accompanied with any un- commonly bad symptoms, pre-dispose to good health and long life. Unless these fevers, says Boerhaave,t are malignant, they dispose the body to longevity, and purge it from inveterate dis- orders. Nor do I believe, his commentator Van Swieten ob- serves, that any physician who has considered this disorder will deny that after quartan fevers, disturbed by no powerful remedy, but gradually resolved by a good diet, in the spring time, the body has been found more firm, and much less subject to diseases than before.i These opinions however are far from being well founded, and have often done harm by preventing the endeavours ofthe practitioner to stop the fever at an early period, which we shall find in at least ninety cases of a hundred ought to be done. But it is not to be denied that agues supervening on other dis- eases, sometimes relieve them. Habitual rheumatisms, inflam- mations, cutaneous eruptions, indigestions, epilepsy, histeria, &c. Dr. Fordyce|| observes, are relieved by a regular tertian. The quartan, says Vogel,§ has ofttm prevented goat, asthma, con- vulsions, and hypochondriacal affections j and even Hippoc- rates says that the quartan is a safe fever and prevents others. Those affected with convulsions, he adds, are relieved from them by a quartan. Intermittents are also said to relieve or remove palsies and other complaints. Some are inclined to doubt of many effects of this kind which have been ascribed to them.! When an intermittent relieves a worse disease, it should not be stopped without caution; and we shall find that in certain * See observations on these effects of intermittents, in Strack de Fe- bribus Intermittentibus, Brocklesby cnthe Diseases ofthe Army, Jackson on the Fevers of Jamaica, &c. | Aph. Boerhaavii. X Comment in Aph. Boerhaavii. || First Dissert on Simple Fever. § Pralect. Acad, de Cog. Cur. Morb. H See some observations on this part of the subject, in a Treatise on Ma- lignant Intermittents by Aurivilius, in Baldinger's Syllcge Opusculoiam, $i INTERMITTING AND cases, even where this does not happen, attempting to stop the fever early, is attended with bad consequences. In by far the greater number of agues, however, more is to be apprehended from too late than too early an use of medicine. SECT. IV. Of the Prognosis in Intermittents. ALTHOUGH the prognosis in intermittents might be gath- ered from what has been said, the danger being upon the whole in proportion to the violence of the paroxysm, and the shortness and incompleteness of the apyrexia, or remissions ; yet, on ac- count of the number and variety ofthe symptoms of those fevers, a few observations on it here will be proper; notwithstanding such observations must partly consist of a repetition of what has already been said. This, however, I shall endeavour to avoid as much as possible. As the prognosis in intermitting fever is collected from the symptoms ofthe paroxysm, and the state of the patient between the paroxysms, it may be divided into two parts. I shall, in the first place, take a short view of the state of the different functions, which during the paroxysms chiefly indicates danger. The weakness and irregularity ofthe voluntary motions become more and more remarkable, as the state of the patient becomes more dangerous. He is troubled with involuntary twitchings of the muscles, (subsultus tendinum) and startings, which often terminate in general convulsions, in which he expires. For some time before this happens a degree of coma generally eomes on, and as death approaches it is often impossible to rouse the patient by any irritation whatever. Nor is delirium a more favourable symptom. In intermittents, indeed, it is to be regard- ed as denoting even more danger than coma. The danger is very great when delirium is among the first symptoms of the complaint, as happened in several epidemics above alluded to, and that of Bangal, described by Dr. Lind, in which the patient generally died in the third paroxysm. T°,.thlS,heaS. 61 a fatal apoplexy. In this, as in most other diseases, death often approaches with a paleness, shrinking, and coldness ofthe extre- mities ; the pulse then for the most part cannot be felt at any considerable distance from the heart. Nor, on the other hand, is the complaint to be regarded as free from danger, when the pulse is remarkably strong and full; this state of it however we have it more in our power to correct The respiration is also much affected as the patient draws to- wards his end ; it becomes anxious and quick, though often at the same time less frequent than natural, interrupted with Sighs and groans, and a little before death sometimes suffers conside- rable intermissions.* Under the head of respiration, it may be observed, that hiccup is a dangerous symptom, if it occurs while the others are alarming, especially if accompanied with vom- iting.* > Every change in the voice from its natural \ov.e indicates dan- ger, and the total loss of speech is often the forerunner of death. Ofthe state of the natural functions indicating danger. Much hausea, the abdomen swelled, hard and painful to the touch, with Obstinate costiyeness, are dangerous symptoms ; a hard belly, and a swelling of the tonsils, are regarded by Sydenham as fatal symptoms in autumnal agues. It often happens that for some time before death the patient is unable to swallow, the tongue, mouth, and fauces generally becoming very foul. " The danger " (says Dr. Jackson) is very great when the tongue is immode- " rately dry or black, or covered with a white slimy gelatinous * This intermission of the respiration is seldom very remarkable ex- cept when the patient dies much exhausted, and affected with coma. It is frequently more considerable in other complaints where die brain is nnre particularly the seat of the disease. Dr. Whytt takes notice of its bciug a common symptom in the hydrocephalus interims. I happened to meet wich a case m which it was more remarkable than in any I have read of; the patient (a boy suspected to labour under an affection of the head) had been long complaining and was much reduced. Before his dcadi a considerable degree of coma came on, and his breathing for about the last half hour was so much interrupted diat there were not less than six or eight minutes between each inspiration, so that his friends thinking hini dead, repeatedly closed his eyes, and were astonished a short tinieafter tohearhim malie a very sonorous inspiration. f When this !s the case, although the patient does not complain of much pain, there is reason to suspect inflammation of the stomach or du- edenum, especially if he complains of pain on pressure about the region of the stomach. It must also be kept in view, in the treatment of agues, that whenever much difficulty of breathing occurs, especially if attend- ed with a degree of hardness in die pulse, we have reason to suspect inflammation of the lungs or its membranes. In speaking of the phleg- masia we shall have occasion to consider at length the symptoms deno- ting the presence of inflammation in the different viscera, and the cir- cumstances in which it is most apt to occur. I make these observations respecting it here, because in the treatment of intermittents. we must al- ways be prepared for its appearance. Vol. I. I 68 INTERMITTING AND « termittents, Vogel* observes, are often removed by cutaneoun eruptions, particularly the miliary eruption, and small pox, oy the hamorrhois, by a salivation, or by an ulcer of the lips. A variety of quotations from different authors might be given to the same purpose. My reason for not entering at present into u particular consideration of this set of symptoms, which have been termed critical, I have already given. It is to be observed, that the most obstinate intermittents are not always the most dangerous. Of all intermittents, tertians upon the'whole are removed with most ease, and quartans with most difficulty. Hippocrates has pronounced a quartan the long, est and safest of fevers. This observation applies only to the simple quartan; when the quartan has suffered a reduplication of its paroxysms, the prognosis in it is no better than in other intermittents. The quartan is a safe fever (Celsus^ observes) and is never fatal; but if it become a quotidian, the patient is in great danger. Upon the whole, intermitting fever, though often a very obsti- nate,is not generally a very dangerous, complaint.^ The symptoms enumerated as affording an unfavourable prognosis, seldom make their appearance, unless it has suffered a reduplication and pro- traction of its paroxysms, or is complicated with other disorders, and then the danger cannot be ascertained without being ac-* quuinted with the prognosis in those disorders. Epidemics in-r deed occur, which form an exception to this observation, as that of Bengal, described by Dr. Lind, Death may happen in any of the stages of intermittents. It most frequently happens in the hot stage. In the quartan in- deed, Sydenham observes, death in most cases happens in the cold fit ; wc shall presently find that the cold fit is more severe in the quartan than in other intermittents. The patient rare-! ly dies in the sweating stage ; if he is much reduced however, and the sweating profuse, death may happen at this period also ; and now and then he i .carried off during the remission, often in consequence of the violence of the preceding paroxysm. If the first paroxysms of an intermittent are mild, the progno-; sis is good ; if from being severe they become mild, it is still better. Bat we must not form a decided prognosis from the mild- ness of one or two paroxysms, and the health of the patient du-< ring their intermissions. It often happens that the first appear i ance of intermittents is very deceitful. It may upon the whole be remarked, that the danger is rath- er to be. estimated from the severity of the paroxysms, than from the length and completeness of the apryexia.f It has been ob- * Pra. Acad, de Cog. et Cur. Morb. t There are some good observations on this part cf the subject, in the first chapter of the third book of Torti's Therapeutice Specials, w INTERMITTING AND « substance. To the above we may add, a sodden or parboiled - * appearance of the tongue, which indicates much danger. A spontaneous, or what has been termed colliquative, diarrhoea fre- quently precedes death. And the uncommon fetidness of the stools sometimes gives reason to suspect that some part of the intestines is sphacelated, which is always a fatal accident.* A black matter like coffee grounds, discharged either upwards or downwards, denotes much danger; this symptom is generally the consequence of hemorrhagy from the stomach or bowels. In the remittents of warm climates the vitiated bile sometimes produces a similar appearance, and sometimes in the stools it assumes that of tar or molasses. Whatever be the matter eva- cuated, vomiting, although not attended with hiccup, is dangerous, :f it does not abate towards the end of the paroxysm, especially 'if attended with much anxiety, and if the discharge docs not bring relief.f The urine or sweat being offensive, the former of a dark colour, and depositing a brown or blackish sediment; tho latter, which js a more rare occurrence, tinging the patient's linen with a brown colour; both of which appearances proceed from an admixture of blood j and the eyes being suffused with blood ; are among the most alarming symptoms.i The sphincters are relaxed be- fore death, so that the urine and feces are frequently passed involuntarily. It may be observed upon the whole, that much danger is indi- cated by the various symptoms denoting great debility in the natural functions. These v. ill be enumerated more at length when we consider the symptoms of typhus, to which fever they properly belong. In the last stage of the paroxysm, a free and thin sweat uni- versally diffused, not occasioning much loss of strength, tends to form a favourable, the opposite of these, an unfavourable, prog- nosis. I shall conclude this part of the prognosis with the following observations from Dr. Rollo's account of the diseases of St. Lucia. " A comatose disposition, (he observes) remarkable dejection, « coldness of the skin, partial cold sweats, hiccup, involuntary " stools, subsultus tendinum, loss of speech, &c. were certain '• signs of danger. When flies become numerous about the « patient's bed in any period of the disease (he adds) and adhere " to his hps and eyes without his being sensible of their attach- * If there is much bile in the prima via, tlie stools may be unusuailv fetid without indicating sphacelus. y unusu^iy or^uodenuiu^ "^ ^ ^ ™^~ to dread mflanima«<>B of the stomach ^S^^SS^^^^^^^^ alluded to, which REMITTING FEVERS. 67 ■" ment, it is a certain mark of danger. Indeed these insects ne- " ver made their appearance in any number until danger, by u other signs, was too apparent. With respect to the prognosis during the remission, or apy- rexia, in proportion as these are shorter, and less complete, the danger is greater. A simple quartan is a safer fever than a tertian ; a simple tertian is safer than a quotidian; and this be- comes the more dangerous, the more its paroxysms run into each other. These observations by no means apply universally, but they should be kept in view. If the patient, during the apyrexia, even although this be com- plete, icc!s himself weak and oppressed, especially if there be a tendency to oedema in his feet and legs, he is not free from dan- ger. We should inquire, Burserius observes, if on the days of intermission the tongue be dry and rough ; if the patient be un- quiet, listless, and apt to sigh; if he be subject to vomiting or purging ; if he be drowsy; or, in short, disordered in any other way ; for then we may suspect some lurking mischief. If these symptoms proceed from no evident cause, he adds, we dread in the ensuing paroxysm cardialgia, cholic, lethargy, or some such alarming symptom.* All combinations of other complaints with intermittents, are to be regarded as dangerous. Visceral obstructions are apt to render the fever more obstinate, as well as to give rise, (as has been observed) to other complaints. THE state of the symptoms affording a favourable prognosis, may be readily collected from what has been said of those afford- ing an unfavourable one. The* symptoms ofthe paroxysm being moderate, the patient bearing them without muchjlossof strength, and enjoying good health during a long apyrexia, are the best signs. In fevers in general, as well as in those I am speaking of, the failure of the sight above alluded to is an unfavourable symp- tom, while deafness on the other hand is generally, though not universally, a favourable one. There is a particular set of symptoms which occur now and then in all kinds of fever, and have generally been observed to attend, and generally supposed to occasion, a favourable change in the state of the complaint, and often perfect recovery. " An crup- " tion about the mouth and ears, (says Dr. Rollot) with a swelling " of the upper lip, either in this fever, or in the intermittent, " happening when the paroxysm was going off, was a certain " sign of recovery, except when the other symptoms were dan- " gerous ; these then assisted the unfavourable prognosis." In- * Frank gives a good account of the symptoms which afford a bad prognosis during the apyrexia. See his Epit. de Cur. Hominum Morb vol. 1, p. 59. t See his Obs. on die Dis. of St. Lucia. REMITTING FEVERS. 6> served of complicated intermittents, that those are most to be dreaded whose paroxysms arc most severe on the even days. Some attempt to foretel the period at which the fever will ter- minate favourably, by attending to that at which it comes to its height ; that is, the time at which the paroxysms from becom- ing more violent, begin to become less so ; for it is common in these fevers for every paroxysm, during the first intervals, to be more violent than that which preceded it. " The tertian inter- " mittents, or remittents, which come to their height in the " fourth period, (Cleghorn observes) terminate in the fifth or " sixth; those which come to their height in the fifth, termi- " nate about the sixth or seventh." Cleghorn speaks ofthe ter- tians of Minorca. No general rules of this kind can be laid down. Every one must make such observations for himself in the particular climate, and even epidemic, in which he practises. It is sufficient to be warned, that by making such observations he will be enabled with more accuracy to foresee the event of the disease. When a paroxysm occurs, which, without any evident cause, is considerably more severe than those which preceded it, it has often been observed to be the last paroxysm of the fever, the patient after it remaining well.* TO the head of prognosis, belongs the doctrine of critical days. This doctrine the reader will find noticed in the writings of physicians ever since the days of Hippocrates, who paid partic- ular attention to it. Some regard the doctrine of critical days as wholly unfounded. This opinion, however, appears to be the result of a careless view of the subject. In this country indeed the facts brought in support of it are seldom to be observed. But the complaints of different climates vary much, and the observations on which the doctrine of critical days is founded, have been too frequently re- peated to permit us to doubt that there is a tendency to certain pe- riodic changes in the fevers of warmer latitudes. Physicians were soon led to observe the crises of fevers, viz. changes, often sudden, either for the better or the worse, which take place in them, and to mark the days on which these, par- ticularly the favourable, changes were observed to happen. Having observed a crisis take place in more than one patient on tlie same day ofthe fever, they were led to pay attention to this < day in other cases, and when they found a day, as the 2d, 3d, 4th, Sec. of the disease on which a crisis happened more frequently than on most other days, this day they termed a critical or judi- cial day. * Fordycc's second Dissertation on Simply Fever, tn INTERMITTING AND Thus the days, during which a fever lasts, came to be divided into those which are, and those which are not, critical. It is to be observed, however, that there is no day on which a crisis nev- er happens ; but there arc some on which it is observed to happen more rarely than on most others. Thus, the 7th is a critical day, since crises happen frequently upon it ; whereas the 12th or 16th are not critical days, since crises very rarely take place on them. Those numbers which are made up by adding alternately four and three (with an exception I shall presently point out) denote the chief cri-'c-.l days, the 4th, 7thj 11th, 14th, &c. that is, the 4th and last day of each week, counting from the beginning of the complaint.* The other days on which crises frequently happen are termed, by Galen, coincidental; and are esteemed an inferior class of critical days, on which crises do not happen so often as on the true critical days. When crises happen on the coincidental crit- ical days, Galen taught that the natural course of the disease is disturbed by some irritation of the system, or by a new attack of the complaint; thus he calls the 7th a good critical day, but the Sth a bad one ; for he supposed that a favourable crisis happening on a coincidental, was less to be depended upon than that hap- pening on a true critical, day-t In the first septenary, that is, the first week, there are many coincidental critical days, because, according to the Ancients, tlie violence of fevers which run their course in so short a time as one week, often disturbs the crisis which ought only to hap- pen on the 4th or 7th day. In the second septenary, the ninth is esteemed almost the only coincidental critical day; thus.-it is, that after the 14th day, the coincidental critical days are of little consequence, the crises generally happening on the true critics) days. * Dr. Cullen considers all the uneven davs, the 5d, 5th, Scc-tothelldi, as critical days. After the Hth he regards every third day as critical. ........^. „t w^.u.mb iulUw.iiauiuicu)urbi- (i mem ; aim iurther, because it is probable that in fevers long protracted, the movements ' become less exact and regular, and'Uiereiore less easily observed " See Dr. Cullen's First Lines, vol. L t The opinion that the course of the fever is disturbed when the termi- nation happens on any other but a critical dav, seemed farther confirmed by the observations ot Hippocrates ; from which it appears, that although the tatal, lj.ee the favourable, terminations generally happen on critical (.ays, yet a much larger proportion of the former, than of the latter happen on the non-critical days.' Thus, Dr. Cullen remarks, all the ter- mi.iations ot fevers mentioned in the writings of Hippocrates, which hau- penedo* tke 6th day, were cither fetal, or not finally salutary H REMITTING FEVERS, *r Hippocrates observed, that the crises happened very often on the 4th day of the first and second week, that is, on the 4th and 11th days of the disease. These days he therefore esteemed o£ much importance in fevers. But as he observed the crisis to happen very frequently on the 17th day, he considers this the 4th day of the third week, so that he makes the third week begin on the same day on which the second ends. Then the 20th day, not the 21 st, is the last day of the third week, and this also he thought a chief critical day ; of all these days crises are said to happen most frequently on the 17th. The critical days which follow the 20th are the 24th, 27th, 34th, 40th, not the 41st, which is the 7th day from the 34th, for the same thing takes place in the 6th week, which happens in the 3d, namely, as the 3d begins on the same day on which the 2d ends, so the 6th begins on the same day on which the 5th ends ; thus we count but six days for each of these weeks. The same happens in the 9th, 12th, 15th, and every succeeding 3d week, therefore the 60th, 80th, 100th, 120th days, arc critical days. Notwithstanding what is here said, Hippocrates remarks, that fevers, unless they leave the patient on uneven days, usually re- turn ; the most favourable termination therefore generally takes place on uneven days. In some places he calls the 21st a crit- ical day ; these passages are by many believed to be spurious. This, says Van Swietcn, is very probable, since there is no mention of the 21 st day in the histories of the cases given in his book of epidemics.* Certain terminations, according to the Ancicntr>, are more apt to take place on certain critical days than on others ; thus Galen says a fever seldom terminates by sweat on the 4th day, and Hippocrates omits this day in enumerating the days on which fevers are generally terminated by sweat. It was supposed in- deed that fevers seldom terminate by sweat on an even day ; and in the aphorism just alluded to, Hippocrates calls the 21st, not the 20th, a critical day. Sweats, he observes, in febrile patients are good, if they begin on the 3d, 5th, 7th, 9th, 11th, 14th, 17th, * In the doctrine of critical days, as delivered bv Hippocrates, how- ever, there certainly arc contradictions; this Dr. Jackson attributes to his having related some cases f.om memory, and others only in part given him by different persons; he observes also, that when the fever begun in the evening, or during the night, Hippocrates generally reckoned tlie following the first day of die disc::;x\ Dr. Jackson adds, that the 22sc is too freq-ienUy mentioned in the writings of Hippocrates as a critical day, to be considered, as Van Swieten and Dr. Cullen suppose it to be, an error in the original manuscript. Dr. Cullen ascribes many of the contradictions in the doctrine of critical days, as delivered by Hippocrates, to his opinion respecting the supposed power of numbers, to which he attributes his doctrine of the quartcaary and ieptenary periods, and his. opinion respecting odd d^ys. ra INTERMITTING AND 21st,* 27th, 31st, or 34th days, for the sweats which happen fto^ on these days denote length of the disease, difficulty, and return of it. It was also taught by the Ancients, that each critical day serves for indicating what may be expected on the next; and in this way the doctrine assists'to form the prognosis. If on a critical day the patient finds himself better, although On the next dav he relapses into his former state, the physician may expect a more remarkable remission on the following criti- cal day. On the contrary^ if (he patient finds himself worse on a critical day, a still more unfavourable change is to be looked for on that which follows, although during the intermediate days the symptoms become milder. From critical days being serv- iceable in this way, they have been termed indicating or judicial days; the physician forming his judgment respecting the future changes ofthe disease from what happens on these days. Thus every critical day is an indicating day to that which succeeds it. Admitting this, it follows that by carefully attending to the Severity of the symptoms on these days, or tl*e degree of relief obtained, we may not only form a conjecture respecting the ter- mination of the fever, but also concerning the distance of that termination. If on the critical days the violence of the symptoms be much increased, we dread a fatal termination, and we judge this nearer or more distant according to the degree of exacerba-* tion which takes place ; on the other hand, if a remission of the symptoms happens on the critical days, we expect a favourable termination, and judge of iis distance from the degree of the remission. In proportion as the disease is slower in its progress, the cri-< itical days' are more distant from each other: thus in fevers which do not exceed three weeks, the 4th, 7th, llth, &c. are critical fldys; but if the disease extend itself beyond three weeks, then only one critical day in the week is to be looked for ; lastly, when the disease continues above forty days, Hippocrates esteems only every 20th day critical, to wit, the 60th, 80th, and 100th, &c. It is also to be remembered, that in lingering fevers the crisis does not happen precisely on the day called critical, but about that day. Such is the doctrine of critical days delivered by the Ancients* * It has already teen observed that Dr. Cullen supposes the 21st day by mistake put for the 20th. Realleges that in continued fevers the tertian type prevails on the llth day, and from this day to the 20th the quartan type. But, admitting what he says of the 21st day to be iust he attempts m vain to reconcile his view of the dectrine of rr=tir .1 ,i\v« with what is said of the 4th day in die writings*S^SJs^uSSI wc admit v. hat he alleges, and what in part if pmlmB^that the wS in« attributed to Hippocrates are in fact the works of diflferen nCS and that the most genuine of them have suffered corruptions 1 V REMITTING FEyfRS. 73 and v.e donot.find in modern authors any addition of consequence to their observations on it, if we except what is said of the appli- cation of this doctrine to intermittents of complicated types by Dr. Jackson, in his account ofthe diseases of Jamaica. The reduplication of paroxysms, which often takes place in intermittents, occasions some difficulty in applying the doctrine of critical days to them. Dr. Jackson, in making this application, considers a double intermittent as two fevers, the one consisting of the original, the other of the new, paroxysms. " Thus if the fever (he observes of tertians) which began on " the odd day was critical, that is, if the paroxysm ofthe odd day " terminated the disease, the crisis was necessarily on an odd " day ; but if that fever, (namely that consisting ofthe paroxysms u which supervened upon the original ones) the first attack of " which was upon the even day, consisted of an equal number of " paroxysms with the other, or continued after that had ceased, *l the crisis was then on an even day, reckoning from the begin- " ning of the illness, thougii still on an odd day dating from the " commencement of the second fever. It was the observation of f< this fact which first gave me tho idea of calculating the critical «* days by the periods of the disease."* By simplifying intermittents in this way, Dr. Jackson observes that their crises will be found to happen as regularly on the criti- cal days as those of continued fever. Of 60 cases which under his care terminated favourably, ten terminated on the 3d day, ten on the 5th, twenty on the 7th, ten on the Oth, five on the llth, three on the 13th, and two oh the 17th. This nearly coincides with what Hippocrates says of the days on which fevers are ter- minated by sweats, which has just been quoted. " Of nine cases which terminated fatally, (Dr. Jackson con- f< tinues) one terminated on the 6th, one on the 7th, six on the M 8th, and one onjrtie 10th." The even days, he observes, were fatal in the proportion of three to one, which he accounts for in the following manner. The paroxysm which destroyed life, like most other changes, tool; place on the odd day ; this paroxysm seemed to decline after the usual duration. It left the body in some measure free from disease, but so completely deranged the vital functions, that life, although it went on for a little could not be long continued, so that death generally happened on the next, that is, the even day ; but it was the consequence of a violent paroxysm which had taken place on the odd day. It also sometimes happened that the patient was tolerably well * Dr. Jackson always reckoned the period of the tertian 48 hours, al- lowing that time for every revolution, although it was sometimes comple- ted in less. As tor quotidians, he observes, the1 c: i . i were generally on an odd day. How shall we reconcile the crises of quartans with the fore- going observations ? Vol. I. K 74 INTERMITTING AND after this severe paroxysm, but a new one recurring after a short interval, speedily terminated his existence on the even day. " Hence we may see, he observes, why the patient sometimes " died on the odd day when the fever was very violent, for thei> " he died in the height of a severe paroxysm, often carried off " by convulsions, apoplexy, or some other accident." Dr. Cleghorn has observed, indeed, of complicated intermit- tents, that the great changes of the fever are always most apt to happen on that day on which the most severe paroxysm takes place, whether this be the odd or the even day. This observation is readily reconciled with Dr. Jackson's, as'Dr. Cleghorn reckons in the usual way without simplifying the complicated types.* Many-of the first physicians of antiquity endeavour to assign the cause of these periodic movements in fevers. Most of their opinions, however, are now justly regarded as without foundation, and many of them indeed are quite whimsical. The most an- cient was founded on the Pythagorean doctrine of the power of numbers. Hippocrates seems to have been of this opinion ; Ga- len disclaims a doctrine so absurd, and conceives that the crises of fevers are caused by the changes of the moon. This opinion long met with the general assent of medical ^authors, and we shall find that an opinion very similar to this, and claiming the autho- rity of extensive observation, has been maintained by some late writers.f SECT. V. Of the Symptoms peculiar to the different Types. We have now1 considered the symptoms essential to, or atten- dant upon, intermitting fevers in general. It is proper, however, before we leave this part of the subject to say something of the symptoms peculiar to each of the three spechjs, the varieties of which have been considered. In the first place, of those peculiar to the quotidian. The quotidian is comparatively a rare fever ; we often indeed meet with intermittents whose paroxysms return every dav ; but most of these are double tertians, in which the fits do not'return * It is remarkable, that we still find something in the severity of tha pai-oxysm which disposes tq health. It was formerly observed of double tertians, that the most severe paroxysm is generally followed by the most complete apyrexia, and that in intermittents in general an usually severe paroxysm often proves the last of the disease; the patient remaining well after it. ° f These are the mo:,t celebrated opinions on the subject; it would be equally mi'-pending time to trouble the reader with any more, or to enter on any refutation cf these. The more modem opinion alluded to in the text, which L not wholly unfounded, 1 bhall presently have ctcasion to consider. REMITTING FEVERS. 75 every day at the same hour, or if they do, are dissimilar, that is, not of the same duration or degree of violence, or not having the violence and duration of their different stages in the same pro- portion.* It is observed by Dr. Cullen, in his definition of the quotidian, which has been quoted, that its paroxysms occur in the morning. This is generally, but not always, the case. In the quotidian the cold stage is shorter, less severe, and more frequently wanting than in the tertian or quartan. But the whole paroxysm is generally longer than in either of these fevers ; and the quotidian is more apt than any other to assume the con- tinued form. Any of the others, about to become continued, in the first place so far assume the appearance of the quotidian, as to have a paroxysm every day. Galen says, every physician ought to know, from the appear- ance of the first fit, of what type an intermittent will be. He gives the following diagnosis for distinguishing the paroxysm of a quotidian. The heat is more moist than in other intermittents, and joined with a kind of acrimony,! which is not immediately perceived on applying the hand ; the thirst is less, and there is a discharge of phlegmatic humours, by vomiting and stool ; the body abounds with crude humours ; the patient's age or habit is too moist, and the season of the year, or state of the weather, is damp. In a quotidian, he adds, there is never so great heat as in the paroxysm of a tertian. We cannot, however, trust to this diagnosis in predicting the type of the fever, although it is not to be altogether overlooked. The most prudent plan, in all cases, is to watch the return of the paroxysm before we give a name to the disease. Whatever the extensive practice of Galen may have enabled him to do, it is now generally admitted that we can seldom determine the type of an intermittent from the symptoms of one paroxysm. Upon the whole, however, a mild paroxysm coming on in the morning, particularly in the spring, often proves a lit of the quo- tidian. The simple tertian, for the most part, comes on about mid-dav, and returns every second day a^ the same time. The cold stage is generally longer and more severe than that of the quotidian, * The quotidian, Eller observes, is a more uncommon fever than either the tertian or quartan, and some writers have regarded all quotidians as double tertians, altogether denying the existence' cf a simple quotidian. But we thus distinguish the quotidian and double tertian ; all the fits of the former are similar and come on at the same time of the day ; this can only be said of the alternate fits of the latter. See Eller de Con. et Cur. Morb. ^ t See Observations on the Heat in Typhus, in b. ii, c. i. of this vol 76 INTERMITTING AND but the whole fit is shorter, in most cases not exceeding ten or twelve hours, and often terminating in five or.six. The cold stage in the tertian is upon the whole less severe than in the quartan, and of shorter duration ; but the whole paroxysm of the former is generally longer. Galen observes, that at the commencement of the paroxysm of a tertian, there is often a painful sensation like pricking ; the thirst (he remarks) is always urgent, the heat very great, and universally diffused over the body ; that this heat strongly affects the hand of the physician on first touching the patient, but soon afbr seems to be less than that of his own hand. Such observa- tions on the heat in fevers seem at first view whimsical; we shall find, however, when we come to consider certain kinds of continued fever, that they are not altogether unfounded.* Eller maintains that the cold is more considerable in the ter- tian, and confirms Galen's observation that the heat is greater (calor magis urens) than in other intermittents; Hoffman, Hux- ham, and others, have also endeavoured to point out some circum- stances which characterise a paroxysm of the tertian, but there is no diagnosis which enables us with any certainty to distinguish it from the paroxysms of other agues. Nor are we enabled to do so by the lime of the day at which this fever appears. It is ob- served indeed, in the definition, that its accession is about mid- day, and it frequently is so, but it aiso often makes its attack at other times. In double tertians the fits are sometimes alternately before and after mid-day ; in these cases it has been observed, that the paroxysms which occur towards evening are generally more severe than the morning fits. The tertian is sometimes, but rarely, protracted for several months; in autumn it now and then becomes a quartan, and is protracted for a much longer time. The tertian, as observed above, is upon the v\ hole less obstinate than other intermittents. But Frankf has justly remarked, that of all intermittents it is the most apt to become malignant, and appears most frequently as an epidemic. If any exception may be made to the former of these observations, it is with respect to the quotidian when it appears in autumn, which it rarely does. The vernal intermittents are almost always either quotidians or tertians. Vernal intermittents, Sydenham! considered as not * It is almost unnecessary to observe, that it is not here meant that there are two kinds ot heat but the peculiar secretion fiom the «kin in certain fevers, affecting the hand at the same time, modifies th~ sensation produced by the increase of temperature. Seethe observations of Sir John r-niijde, Huxham m ms work on.Fevers, Moore in his Medical Sketches, and others on this subject. I sh^l have occasion to Quotenart ot tueir oubc-i \ at tons, when speaking of Cundnued fever. T Epitome de Cur. Horn. Morb. X Sydenhami Opera Sect, de Feb. Intermit. REMITTING FEVERS. 77 only safe but salutary, and if protracted till the autumn, he ob- serves, which season is unfavourable to these species of inter* mittcnts, they generally cease spontaneously. It may be observ- ed, however, on the other hand, that if autumnal tertians are protracted to the following spring, it also generally puts a period to them. The vernal intermittents are less liable to become continued, to be accompanied by dangerous symptoms, or by bilious com- plaints, or followed by dangerous consequences, than the autum- nal ; they are also less disposed to return. I speak exclusively of the quotidian and tertian ; the two first observations do not apply to the quartan, which generally appears in autumn. It has already been observed, that it is less apt to become continued, or to be accompanied by alarming symptoms, than either of the other species. In the vernal intermittents, a considerable degree of excite- ment generally prevails ; in the autumnal, a deficiency of excite- ment, debility. We shall afterwards find the following observa- tion fully illustrated; that we always have it in our power to diminish excitement as much as we please, but in general we find it difficult and often impossible sufficiently to increase it, when it has fallen much below the healthy standard. It is chiefly owing to this circumstance that autumnal agues are more danger*- ous than vernal; and it will appear, as we proceed in considering febrile diseases, that this circumstance also, more than any other, influences our practice in all idiopathic fevers. The regular quartan is an autumnal ague. Dr. Brocklesbv* informs us, that he never saw an instance of a quartan which made its attack in the spring, and his experience was very ex- tensive.'t The quartan generally attacks in the afternoon ; the cold stage upon the whole is more severe, and of longer duration, than that of either the quotidian or tertian ; it generally lasts for about two hours, and sometimes longer. Dr. Grants says, he has seen a cold fit oi the quartan last fifteen hours; but it is not always ac- companied with much sickness or vomiting; and Filer and others observe, that the sensation of cold is not in general so great as in the cold fit ofthe tertian. The whole fit of the quart n is generally shorter than that of either the quotidian or tertian. * Dr. Brocklcsby's Observations on the Diseases of the Army. t We shall find, in speaking ofthe causes of intermittent?, that in the climates where the changes of the seasons are lcmarkable, spring and autumn are those in which intermittents most frequently appear. X Dr. Grant's Observations on Fevers most frequent in London. 71 INTERMITTING AND At the invasion of quartans, Galen observes, the pulse is as if it were bound up and drawn inwards, nor is there that sense of painful pricking which we meet with in the cold fit of the tertian, but the patient feels as if all the soft parts were bruised. The following short quotation from Eller's Observations, contains perhaps the best diagnosis that can be given of the paroxysm of a quartan: The cold, he observes, is not so violent as in the ter-< tian, but of longer duration; the heat is more gentle and dry, and the sweating is scanty.* • The quartan is more apt to be followed by obstructions of the viscera than other intermittents, owing probably to its being more obstinate, for although its paroxysms are shorter than those of the quotidian or tertian, its duration is generally much longer. It is often the most obstinate of all fevers, and has like the gout been termed the Opprobrium Medicorum. Some authors assert that they have known a quartan last for twenty or thirty years. It is a remark of Sydenham, however, (how far it is generally applicable it is difficult to say) that if a person be attacked by a quartan for the second time it generally goes ofi" after a few fits. After a quartan, which has proved obstinate, and 'n which the fits have been attended with delirium, the patient has been known to remain in a state of fatuity for a long time, as happens more fre- quently after that species of continued fever, which is most apt to be attended by delirium. The quartan is particularly severe on old people ; young peo- ple generally get the better of it, if not improperly treated, on or before the succeeding spring. Sydenham says, he has been sur- prised to see infants labour under a quartan for six months, and stand it out well. Upon the whole, the principal difference between the parox- ysms of the different species of intermittents, consists in their duration, and the proportional duration of their different stages. In the quotidian the cold fit in general is shorter than in the other two species, but the whole paroxysm is longer. The cold fit of the tertian is longer than that ofthe quotidian, but shorter than that of the quartan, and the whole paroxysm is shorter than that of the quotidian, but longer than that of the quartan. The quar- tan m general has the longest cold fit, but the shortest paroxysm. '1 he duration of the cold fit then in the different types is propor- tioned to that of the intermission. The contrary is true of the duration of the whole paroxysm, which is generally the ioneer, the shorter the intermission. We an? now to consider the man- ner m which the different types assume more or less of the continued form. Many of the facts relating to this part cf the subject indeed have already been mentioned ; it may be useful to present them at one view. * Eller de Cog. et Cur. Morb. REMITTING FEVERS. 7$ SECT. VI. On the Manner in -which the different Types assume more or less of the continued Form. PHYSICIANS have long endeavoured to assign a cause for some fevers assuming the form of intermittents, while others appear continued, at least so much so that the slight remissions which take filuce in them can often hardly be perceived. But how fruitless their labours in this part of the subject have been, appears at the first view of their several opinions. Even Syden- ham's speculations on this subject are but ill warranted by obser- vation. It would be inispcnding lime to enter on the merits of these hypothes:»; let us take a short view of the facts which gave rise to them. When the fits of a quotidian are lengthened, there is no time for any apyrexia, and thus the intermittent is changed into a re- mittent. As the paroxysms arc protracted, the remissions ap- pear less remarkable, and the fever at length completely assumes the continued form. The tertian, we have seen, is apt to suffer a reduplication of its paroxysms, and then this fever also may readily assume the con- tinued form : for it is an observation generally applicable, that when a reduplication of the paroxysms takes place, the new are not only more protracted than the original paroxysms, but these also become more protracted than they were before the accession of the former. Although the paroxysm upon the whole is pro- tracted, the duration of the cold fit is diminished as that of the hot is increased, so that when the fever has assumed the contin- ued form, the cold fit in general is scarcely to be perceived. It is also to be observed, that when an intermittent assumes the continued form, the symptoms of the hot stage in proportion as it is protracted generally become more severe, and those ofthe cold stage in proportion as it is shortened become milder. The quartan rarely assumes the continued form. The quarta- na triplex, in which a paroxysm happens every day, sometimes though rarely appears. This form of the quartan if it suffers a reduplication of its paroxysms may readily become continued. The new paroxysms added to a tertian or quartan, when they become double for instance, always resemble the paroxysms of the first fever in this, that they are of the same type. Thus in a double tertian, the paroxysms of every second day are similar, and this is as constantly the case with respect to the new as the original paroxysms. But the new are seldom similar to the old, or recur at the same time ofthe day. It is by this circumstance, we have seen, that we distinguish a quartan or tertian in which the fits return every day from a simple quotidian. 80 INTERMITTING AND Van Swieten observes that, as far as he knows quintans and other intermittents of more protracted types are never changed into continued fevers. It will afterwards appear, that the chief if not the only circum- stances which determine intermittents to assume more of the continued form, are the presence of much debility, or of what has been termed the phlo-i*tic diathesis, which is that state of the svstem that prevails in synocha, and may be considered sy- nonimous'with increased incitement. This ■ is in fact saying nothing more than that the severity of the disease determines it to assume more of the continued form. For we shall find, that in all idiopathic fevers, the two circumstances here mentioned, debil- ity and increased inr itement, are the only sources of danger. It is the latter we most frequently have to combat in intermitting fevers ; the means of removing tl is with safety therefore (that is, without running the risk of inducing the opposite and more dan- gerous state of debility) forms an essential part of their treat- ment. Instead of becoming more continued, intermittents sometimes become less so ; if a reduplication of the paroxysms of a tertian or quartan has taken place, they again become simple, and in proportion as they do so, the remaining fits at the same time become shorter while the cold stage again occupies a greater "share of the paroxysm. Intermittents sometimes assume a more in- termitting form in another way, that is, by changing their type. It is not uncommon for an autumnal quotidian or tertian to be changed into a quartan after the violence of the fever is to a cer- tain degree broken. Continued fevers also change to a more or less intermitting form. When this happens, the continued fever, for the most part, has formerly been an intermittent, or has appeared with in- flammatory symptoms while intermittents were epidemic ; we shall afterwards find, however, that all kinds of continued lever, though rarely, now and then assume the intermitting form. CHAP. III. Of the Morbid Appearances discovered by Dissection, in those ivh* die of Intermitting Fevers. IVJlANY diseases prove fatal, without leaving any trace to be discovered by dissection, i his strictly speaking is true of inter- mitting as well as continued fever. A variety of morbid appear- ances indeed has been observed in those who laboured under agues ; none of these however can be regarded as essentially con- nected with the fever ; none of them seem at all connected with its cause, nor are there any which can be regarded as its immedi- REMITTING FEVERS. 81 utc consequence. It is true, intermittents sometimes prove the cause of other complaints, indurations of the different viscera, See. and in this view may be regarded as the cause of the morbid appearances belonging to such complaints. t But we must be careful not to confound these fevers with their consequences, as some have done, which has given rise to the opinion of intermit- tents depending on certain states of the bile, and to other ill-foun- ded hypotheses. I have had occasion to enumerate the diseases most frequently complicated with agues ; the consequences of these diseases in the different cavities of the body, are those which we find mentioned by writers as the consequences of inter- mittents. The stomach, intestines, omentum, and mesentery are fre- quently found inflamed, or of a dark colour, and sometimes quite sphacelated. The omentum and mesentery sometimes appear wasted ; in other cases have tumours formed on them ; the stom- ach and intestines are often enlarged, the consequence of having been distended with air ; and in various parts of the latter, pre- ternatural constrictions arc frequently observed. The gall blad- der is often turgid, and an unusual quantity of bile is found in the stomach and intestines. The liver is frequently indurated and enlarged, sometimes diminished and of a whitish colour, and it has now and then been found, only six or eight hours af- ter death, soft, and it is said putrid. In some cases it seems gorged with blood, the venx portarum being much enlarged ; in others, it is tinged with bile. The pancreas is also found enlarged, and sometimes ulcerated, more frequently indurated. The spleen is particularly apt to be affected in intermittents ; it is often en- larged, frequently weighing many pounds. Its structure has sometimes been so completely destroyed, that it presented the appearance of congealed blood wrapt in a membrane. In a great- er proportion of cases, however, it is indurated, as well as en- larged ; in this state it has got the name of ague cake, and is felt by the patient himself through the integuments of the ab- domen. ^ This affection of the spleen is particularly apt to occur in the bilious remittents of tropical climates. Strack thinks that boys are more liable to it than adults. The mesenteric and other smaller glands of the abdomen are also frequently found indurated. ^ The viscera of the thorax are sometimes considerably affected. Traces of inflammation in the lungs and pleura frequently ap- pear, and the former are sometimes found soft and gangrenous., The heart too is often flaccid and enlarged, and the vessels ofthe lungs turgid, with dark coloured blood.* When the skin is tin- ged with yellow, the serum in the thorax and other cavities is of course of the same colour. % * This state of the heart and blood-vessels is the consequence of the circulation in the lungs having been much impeded for some time before dcatti, so that it is most remarkable in those cases where the dyspnoea has been most considerable. Vol. I. L 82 INTERMITTING ANT! Morbid appearances of the head in intermittents are less fre- quently observed. Polypi are sometimes found in the sinuses. But these are frequently met with whatever be the complaint of which the patienulies, and must be ranked among those changes which take place after death or in articulo mortis. Traces of in- flammation, and even abscesses, are now and then met with in the brain ;* and the serum in the head, like that of the thorax, is frequently found of a yellow colour. If the patient die in the cold fit, an unusual accumulation of blood, it is said, is observed in internal parts. This is' the only morbid appearance which has been mentioned, that can be regard- ed as essentially connected with the fever, and it is more than probable it has been magnified for the purpose of serving certain hypotheses. CHAP. IV. Of the Causes of Intermitting Fevers. J.T was observed in the preface, that in considering the remote causes of complaints, I should not always treat separately of what have been termed the predisposing and exciting causes, the circumstances which render the body liable to the disease, and those which excite it, since in many instances it is impossible to' say to which of these classes any particular cause belongs, as in many complaints the same circumstances act sometimes as predis- posing, at other times as exciting, causes. In intermitting fevers, however, the remote causes may be more properly divided into predisposing and exciting, than in most other complaints ; since a variety of observations seem to prove that these fevers can only be excited, at least are generally excited, by one cause, namely, exposure to an atmosphere of a particular kind ; so that the other circumstances observed to co- operate with this in their production, can only be regarded as in- creasing the power of that cause or producing a state of body fa- vourable to its operation. SECT. I. Of the predisposing Causes of Intermittents. OF the various circumstances favourable to the action of the exciting cause of intermittents, (the marsh maisma or putrid ef- fluvia from marshy grounds) there are some which operate by ren- * These various morbid appearances will be considered at greater length when speaking of the diseases to which they belong. REMITTING FEVERS. 88 dering the body more susceptible of its action ; others which seem to act by increasing the power of the cause itself ; and some which act in both ways : so that it will be the most distinct plan, and save repetition, to consider the whole, under the head of marsh miasma, as circumstances favourable to its action in produ- cing intermittent fever. SECT. II. Of the Marsh Miasma. THE effects of an atmosphere loaded with noxious vapours on the animal body, are often striking. White females born and constantly residing in the lower districts of the province of Geor- gia, we are informed, have seldom lived beyond the age of 40 ; males sometimes approach to.50. Similar observations have been made respecting some parts of Egypt near the banks of the Nile.* There aie swampy situations in the Carolinas and Vir- ginia which are destructive of life in a still more remarkable de- gree. " I am credibly informed (says Dr. Jacksont) that there " is not on record an instance of a person, born in Peterborough " in Virginia, and constantly residing in the same place, who has ■" lived to the age of 21." Dr. Jackson saw a native of this town who was in his 20th year, but he was said to be the first who in the same circumstances had lived to that time of life ; he was decrcpid as if from the effects of age, and it did not appear that he could survive many months. The influence of marsh miasma, that is, of the vapours arising from marshy grounds, in producing agues, was first observed by Lancisi, about the middle of the Jast century. The justness of the observation is now so generally admitted, that it is unneces- sary to adduce many facts in support of it. It is almost an universal observation indeed that intermit- tents prevail in low marshy countries ; we have ample proof of the fact in our own. Our climate on the whole cannot be regard- ed as favourable to the production of these complaints. In Lin- colnshire, however, and the other fenny counties, there are few complaints more frequent. Near stagnant pools, especially when the weather is warm, they are often so frequent as to deserve the name of an epidemic. In other countries we have still more remarkable proofs of the effects of marsh miasma in producing agues. In Egypt, after the Nile retires, leaving the wet ground covered with a variety of putrifying animal and vegetable substances, these fevers begin to rage. We are informed that the Arabs, when they wish to be revenged on the Turks of Bussarah, break down part of the banks * Bruce's Travels to Abyssinia, &c. 1 Dr. Jackson's Account of the Diseases of Jamaica. 84 INTERMITTING AND of the Euphrates, by which the deserts in the neighbourhood of that city are laid under water. The stagnating water and dead fish soon become putrid, and the most dreadful fevers, generally ofthe remitting form, are the consequence. The fc\crs induced by a single inundation of »these deserts have been known to de- stroy between twelve and fourteen thousand of the inhabitants of Bussarah.* When the cause applied is so violent, as in this case, we sel- dom meet with intermittents. Intermittents and remittents arise from the same cause, but from different degrees of it. " In Ja- " maica (Dr. John Hunter observes) the fevers in the most heal- " thy seasons are generally intermittents; in the rainy and other " unhealthy seasons, remittents." When the degree of heat and moisture is not considerable, the regular intermittents pre- vail, and are in general readily removed by the ordinary means. In proportion as the season becomes hotter and more moist, a reduplication and protraction of the paroxysms take place, till the disease comes at length to. differ but little from a continued fever. And in the more temperate climates, even when the au- tumnal fevers are of the most continued kind, if they arise from marsh miasma, they begin to intermit as the cold weather sets in, and before the winter is far advanced, often terminate in simple tertians or quartans. The true intermittent fever is a complaint neither of very warm nor very cold climates. Bontius.t Lysons,^ Clark,[| and others remark, that it is seldom met with near the equator. The putrid remittent may be regarded as the endemic of sultry latitudes. It is also to be observed, that in the more temperate climates, where intermittents are more frequent, they prevail most at the most temperate seasons of the year, spring and autumn. Upon the whole however, of the climates which may be called tempe- rate, the warmest are the most favourable to the production of these fevers. In such climates as our own they generally pre- vail most when the weather has been for some time unusually warm, particularly when the rains suddenly set in after a warm summer. ^ The dreadful remittent of Bussarah, just mentioned, is always most feared in the hottest seasons ; and the heat of a country where the thermometer often rises in the shade to about 1 15*, may well be supposed to increase the malignity of every epidemic, * The oversowing of the Euphrates, says a person who resided at Bussarah, and its waters stagnating on the desert, have always been ac- counted the principal cause of the remitting fever of this place. See the Observations on the Fever of Bussarah above alluded to, in the Transac- tions of a Society for the Improvement, &c. for 1793. t De Medicina Indorum. X Essays on Fevers, &c. f) On the Diseases in Icr,^ Voyages to hct Climates. REMITTING FEVERS. 85 although it acted in no other way than by the irritation it occa- sions. " When the heats comeon soon,*' Sir John Pringle ob- serves of Flanders, where from the low, damp situation of the grounds intermitting fever is very frequent, " and continue " thr6u Ki'v.ttious respecting it as rebate particularly to the treatment of agues. REMITTING FEVERS. 101 I sliall make a few observations on each of these heads. In the first place then wc are to consider, what the symptoms are which render blood-letting proper in intermitting fever. Wherever the countenance is flushed, the head-ache consider- able, or the delirium obstinate, with a full and hard pulse, blood- letting is necessary. When along with this slate of the pulse the fever assumes more ofthe continued form, or the patient is affected with dyspnoea, we must have recourse to this remedy.*- - It is difficult to point out the degree of excitement which, in- dependent of local affections, or the fever assuming a more continued form, warrants the employment of blood-letting. The use of this remedy in intermittents will be better, understood, after considering its exhibition in continued lever. One observation must be kept in view, that, for two reasons, a less degree of ex- citement warrants blood-letting in intermitting than in contin- ued fever. In the first place, the removal of increased excite- ment, that is, of the symptoms of synocha, is of more impor- tance in jlhe cure of the former than of the latter disease; and because in the former we have less reason to dread the debilita- ting effects of blood-letting. This observation will be sufficiently illustrated when speaking ofthe use ofthe bark in intermittents, and of blood-letting in continued fever. In those cases where there is no increase of excitement, and still more where the pulse is small, frequent, and intermitting, wc cannot do a more improper thing than make use of the lan- cet. With regard to the period of the disease at which it is proper to employ blood-letting, it may be observed, that as the continu- ance of every disease tends to weaken, those symptoms which indicate this remedy are seldom present after the complaint has lasted for a considerable time. Except, therefore a new disease requiring blood-letting supervene, it is seldom proper in pro- tracted cases. At the first attack, on the contrary, it often proves beneficial, particularly in the spring, or at other times when the epidemic has an inflammatory tendency. Blood-letting to a greater or less extent is generally necessary at the beginning of intermittents in warm countries, especially when the patient has lately arrived from a colder climate.t In * When the difficulty of breathing is urgent, as sometimes happens, with a low pulse, and in cafes where the strength of the patient has been much reduced, either by die continuance of the disease, or previous eva- cuations, local means are preferable to general blood-letting. ) Sec Dr. Curtin's letter to Dr. Duncan, in the 9th vol. of tho Medical Commentaries, and the observations inrleed of most authors who treat of tlie fevers of warm countries. " For my own part, (says Dr. Cleghorn, " speaking of the tertians of Minorca) when 1 was called early enough " hi the beginning of thete fevers, I used to take away some blood, unless " there was a strong contra-indication, from people of all ages." '102 INTERMITTING AND warm climates, however, this remedy is always to be employed with much caution. Blood-letting in the hot fit of agues was regarded by the An- cients as a dangerous practice ; succeeding experience however has contradicted this maxim; and it is now generally admitted, that the patient may be bled at all periods of the disease, except during the cold and sweating stages, and at the time the parox- ysm is expected, that is, either in the hot fit, or during the in- termission. If we reflect upon the end we have in view when we prescribe blood-letting in intermitting fever, we shall find reason for con- fining this remedy to the hot fit alone. It has already been ob- served, that blood-letting is not to be regarded as one of the means of a radical cure. It has been a favourite opinion in me- dicine, and still is with many, that fevers depend upon a noxious matter existing in the fluids, and that this may be evacuated by blood-letting. We can perceive however, without very minute observation, that the effect of blood-letting in all kinds of simple fever, that is, of fever which is neither in any degree produced by, nor has itself caused, any local affection, is merely that of diminishing excitement,* which, if violent, threatens a dangerous degree of subsequent debility, and even when but little above the healthy standard, tends to render intermittents obstinate. From this view ofthe subject, it appears that we ought not to employ blood-letting during the remission or apyrexia. The excitement is never considerable at this period, and blood-letting will not prevent it becoming so during the ensuing paroxysm with the same certainty, that it will relieve the increased excite- ment when present. Besides, when the excitement is morbidly increased, the patient bears the loss of blood better than at other times. Dr. Lind regretted that he had bled a patient during the apyrexia ; the event was unfortunate, and he owns that an expe- rienced physician thought it probably would not have been so, had the blood-letting been ordered during the paroxysm. In intermitting fever, therefore, the most proper time for let- ting blood is during the hot fit of the first paroxysms. We arc now to consider, the consequences to be dreaded from blood- letting. The certain consequence of repeated blood-letting, especially when not employed with judgment, is debility, and this now and then is so sudden, even where the quantity of blood lost is not very considerable, that patients have sometimes expired almost immediately after venesection. This has not often happened; the powers of Ufe, however, are frequently so impaired as to render the fever more obstinate and dangerous; or even to un- * See what is said of blood-letting in the treatment of continued fever, in book il of this vol. REMITTING FEVERS. 103 dermine the constitution, and induce dropsy or other lingering diseases. Another consequence of blood-letting, not to be overlooked i» diseases which are of long continuance, is plethora. It is well known that the frequent repetition of blood-letting induces a state of body which renders the discoi.tinuance of the habit dangerous. It only remains to take notice of the circumstances in which the bad effects of blood-letting are most to be dreaded. There are few remedies whose good and bad effects more frequently seem to balance each other than that I am now speaking of; so that cases occur in which the most experienced and acute phy- sicians cannot positively determine whether it ought to be recom- mended or not. The general rule is, that wherever debility is present, or with certainty expected, blood-letting is dangerous; and yet in both these cases we must sometimes employ it. In idiopathic fevers, however, it is only the latter of the difficulties with which we have to struggle. For wherever debility is actually present in these fevers, blood-letting we shall find is decidedly improper. In sultry climates fevers run their course rapidly, so that a pa- tient who is labouring under a strong full pulse, and the other symptoms of synocha, will in a short time be reduced to the last stage of weakness, and the symptoms denoting a dangerous de- gree of debility in the various functions will make their appear- ance. In such cases the violent excitement at the commence- ment ofthe fever, if not relieved, will terminate in this state of debility ; yet the only means we have of relieving it are them- selves of all remedies the most debilitating. Mr. Clark,* after relating the fatal termination of three cases in which blood-letting was employed to moderate the violence of the excitement at the commencement of the remittent of sultry climates, observes, that he has since found it necessary to lay aside blood-letting in such climates, both at sea and on shore, ex- cept when local inflammation was present. What is best to be done in such cases, can only be determined by considering a variety of circumstances, for which I must refer to the observations that will be made, on the same difficulty, when wc speak of continued fever; as these are in every respect applicable in the present case. Blood-letting is to be cautiously employed, whatever be the ex- citement, at the beginning of the complaint, if the epidemic is of a putrid nature, particularly if the'patient is, or has lately been, subjected to the action of other debilitating causes: It must be sparingly used, for instance, in hospitals, where patients are often * On the Diseases of long Voyages to hot Climates. 104 INTERMITTING AND exposed to a noxious atmosphere, and their bodies generally rc« duced by a scanty diot. For similar reasons, blood-letting in more to be feared in large and populous cities, than in the coun- try. In summer and autumn it is a more doubtful remedy than in winter and spring; fevers in the former seasons being fre- quently attended with much debility, which is the source of all their most alarming symptoms. ' " Ablate et aulumno," Burse- rius observes, " sanguinis missio in intcrmittcntibus minus con- venit." In all cases it is to be remembered, that blood-letting is more or less pernicious according to the habit of the patient. Those accustomed to this evacuation, bear it better than others. Our judgment ought also to be much influenced by the age and habit of the patient. People of a plethoric habit, and in the vigour of youth, most frequently require blood-letting, and are least apt to suffer from it. It appears, then, from what has been said, 1. That the symptoms indicating blood-letting in agues ars those of increased excitement, if considerable, or such as denote a tendency to local inflammation. 2. That the period most proper for the exhibition of this rem* edy, is the hot fit, especially during the first paroxysms of the disease. 3. That the consequences to be dreaded from this remedy* are debility and its attendants ; and 4. That, on this account, it is most to be dreaded where the bo-' dy is at the same time exposed to other debilitating causes. Upon the whole, blood-letting is a remedy which generally produces some important effect. If it does no good, it proves hurtful and often dangerous ; and, on the other hand, in many cases where it is indicated, no other means can save the patient. The proper employment of blood-letting, therefore, forms an important branch ofthe practice of medicine. A moderate blood-letting for an adult is ten or twelve ounces, but its extent must vary according to a variety of circumstances, afterwards to be pointed out at a greater length. I shall pre- sently have occasion to make a few additional observations on the use of blood-letting in intermitting fever, when I speak of th» exhibition of the bark. Such are the means to be employed during the hot lit. All that we have to attend to in the sweating stage is, to avoid whatever might tend to check the sweat ; in particular, if it lasts for a considerable time, to give the patient frequent changes of warm linen, that he may not be chilled by wet clothes ; to lay him in flannel indeed is the best plan, if he has no particular dia- REMITTING FEVERS. 105 like to it. If he is much reduced, his strength should be sup- ported by gentle cordials. Before we leave the first part ofthe treatment of intermittents, it will be proper to make some observations oir' The Modus Operandi ofthe Remedies employed during the Parox- ysm.* Ofthe modus operandi of emetics- It is a law of the animal economy, that an irritation applied to any part of the system, generally tends to induce such motions as are calculated to remove it. When these motions are excited in the more minute parts of the animal body, they are traced with difficulty, and the manner in which they act is obscure. Thus an extraneous body introduced beneath the skin, excites inflam- mation and suppuration, by means of which it is expelled; but we cannot trace all the steps of this process. Where the larger parts ofthe animal machine, however, are thrown into action, we trace with more ease the different motions excited, and can often perceive distinctly in what manner they operate in removing the cause of irritation. Thus, an irritation of the nares produces a sudden and violent contraction in all those muscles which are brought into action when we expire forcibly. The consequence of which contraction is a sudden and strong expiration, by which the air being forced violently through the nares, any extraneous body, irritating this part, is removed; Thus coughing also is oc- t asioned by any extraneous body lodged in and irritating the trachea. Wc see an instance of the same thing in the involun- tary exertions excited by tickling the sides or the soles of the feet; so in vomiting, the irritation applied to the stomach induces the action of those muscles which are capable of expelling its con- tents. Concerning the action of the muscles employed, some differ- ence of opinion has arisen. It has generally been supposed that the abdominal muscles and diaphragm act together, by which the stomach being forcibly pressed between these muscles, its contents arc thrown out by the oesophagus. An eminent pro- fessor observes, that as the patient must inspire if the diaphragm contracts in the act of vomiting, part of the contents of the sto- mach, in their passage over the wind-pipe, would be drawn in with the breath. He therefore supposes that the diaphragm im- * If what is here said of the modus operandi of the remedies employed during the paroxysm of an intermittent, appear to the reader too long a digression in laying down the treatment of this complaint, he may pass to the next section, and read this, after he has perused the whole of the treatment in agues, along with the account given of the modus operandi of the means employed during the apyrexia. But the treatment during die paroxysm and apyrexia, are so little connected with each other, that the mode of arrangement I have followed appears to me the most distinct, . Vol. I. O 106 INTERMITTING AND mediately before the act of vomiting, is fixed by a strong perma- nent contraction, and that the contents of the stomach are thrown* out in consequence of the sudden contraction of the abdominal muscles pressing the stomach against the riyid diaphragm. Concerning this theory of vomitim\ it may be observed, that we do not find a muscle acting in the way in which the diaphragm is here supposed to do, in any analogous case. This alone must make us hesitate in admitting it. The following observation, as far as I am able to judge, altogether sets it aside : Both in this and the common account of vomiting, one effect of the violent contraction of the abdominal muscles is overlooked, that of draw- ing down the ribs. In the act of vomiting, the ribs are forcibly drawn down, as any person will feel by applying the hand to the side of the thorax (which I have frequently done) while under the operation of an emetic. By the descent of the ribs then in vomiting, the thorax is narrowed, so that if it is not at the same time lengthened in the same proportion, an expiration must take place. But we know that no expiration takes place in the act of vomiting; the thorax must therefore be lengthened in propor- tion as it is narrowed : but it can only be lengthened by the con- traction of the diaphragm, and this contraction must be instanta- *■ neous, to correspond with the sudden descent of the ribs. That neither expiration or inspiration may take place, the one motion must counteract the effect of the other. We know that if the ribs descend, the diaphragm must at the.same moment either contract or become flaccid, a state in which nobody can suppose it to be during the act of vomiting. It would be prevented indeed from becoming absolutely flaccid by the action ofthe abdominal muscles pressing up the bowels ; but were this admitted, it must be granted that the cavity of the thorax is both narrowed and shortened in a case where no expiration takes place ; while we must at the same time admit that the yielding diaphragm is but ill adapted to the office which wc know it performs in the act of vomiting. All difficulties are removed by supposing that the diaphragm and abdominal muscles contract at the same instaut; the latter drawing down the ribs, lessen the capacity of the thorax in one way, in proportion as the descent of the ciupbragm enlarges it in another. Expiration is forcibly prevented in vomiting to assist in depressing the diaphragm. With regard to the peculiar effects of vomiting, by which it tends to put a period to the cold, and induce the hot, stage of in- termittents, we cannot speak with the same certainty ; there is reason to believe that it does so, both in consequence of the sym- pathy which is known to subsist between the stomach and the surface, and because the agitation which vomiting occasions proves a stimulus to the system in general. With regard to cathartics. Catharsis is induced by a double operation of these medicines, which still act, as in the case of vomiting, by exciting such motions as tend to expel them from REMITTING FEVERS. 107 the body. This they do partly by increasing the peristaltic mo- tion of the intestines, and partly by increasing the secretion from their surface. It is almost unnecessary to observe, that different medicines are fitted to excite diffcrenf parts of the system. Peppers and aromatics strongly affect the taste, and excite a flow of saliva, but they neither occasion vomiting nor purging. The preparations of antimony which act so violently on the stomach and intestines, arc almost insipid. But the remedies employed during the paroxysm of an inter- mit1, ent, whose modus operandi chiefly deserves attention, are opium and blood-letting. In a treatise, entitled an experimental Essay on Opium, I have endeavoured, by comparing the numerous experiments which have been made on this subject, to give a view of the modus ope- randi of this remedy. It would be improper here to enter on any account ofthe experiments by which we arrive at this know- ledge ; I shall only quote from the treatise* the result of what I have there said. * I.i a periodic work the following observation is made on this treatise: " From the experiments made in the treatise before us the author is led " to iuferences widely different from those which have been drawn by for- " mer writers, but which it is to be feared aie still remote from cer- " tatnty." This observation can hardlv be regarded as liberal, shit tlie author of the analysis does not give the reasons which induced him to ma.he it. As other authors had given a different account of the result of several experiments related in my treatise, 1 took an oppotunity in the s.fm- mer of 1796, when lread a course of lectures on febrile diseases at Edin- burgh, of publicly repeating these experiments. But as ift a class the great- er nu'ober of pupils sit at too great a distance to judge of the result of experiments of this kind with much accuracy, at my request many of the gentleman attended on a day on which there happened to be no lecture; t'u .v stood as near the tabic, on which the experiments were made, as their number would permit, and expressed their satisfaction with respect to the result. Many of them were men well acquainted with the sub- ject, and indeed with medicine in general. In the treatise alluded to I have mentioned several circumstances in the experiments in question, which may hare occasioned to others, results different from those wnich occurred to me. A gentleman, however, present at the above meet- ing, Dr. Woolcomb, suggested a circumstance to which I am now inclin- ed, almost wholly, to attribute this difference, namely, that tlie authm-s al- luded to had uot distinguished the spasms induced by an over-dose of opi- um, from the voluntary straggles ofthe animal. Ti«!>: admitted, explains the difference of result, in almost every case, in which I differ fr ; a others. And that the authors alluded to permitted themselves to be de- ceived in this way is probable, because they take no notice ofthe spasms occasioned by opium being of a peculiar kind, a circumstance which must have struck them had they properly distinguished these spasms, which J I) itli in the warm and cold blooded animals, always assume iK- frrm of that species of tetanus which is termed the opisthotonos. Dr. Wool- comb indeed made the observation in consequence of hiving sometime before be i pro x.n': when one of these audnrs ve;>L'ated the experiments without in.iking this distinction ; a want of utteiuion to whiea now ap- 108 INTERMITTING AND The effects of opium on the living animal body may be divided into three classes. The first, comprehending its action on the nerves of the part to which it is applied, does not differ essen- tially from that of any other local irritation. It is doubtful whe- ther the first shock given to the system by the action of opium on the nerves of the part to which it is applied has ever been sufficient to destroy life, A large quantity suddenly applied to a very extensive surface is capable, perhaps, of instantly killing animals less tenacious of life than frogs are, which were the subjects of the experiments above alluded to. A variety of strong impressions, that, for in-. stance, produced by drinking a large quantity of spirits of wine, or of very cold water when the body is overheated, are well known to have occasioned sudden death. From all the facts with which I am acquainted, however, opium never occasions death in this way. The second class of the effects of opium are those on the heart and blood vessels ; namely, that of increasing their action when it is applied in small quantity ;* and that of altogether destroy* ing their action when applied more/freely. In neither of these effects, however, does the action of opium differ essentially from that of other agents. Are not most substances, applied in small quantities, capable of exciting contractions in the muscu* lar fibre, and of destroying its power when applied more freely ? It does not appear, that the quantity of opium absorbed by the lacteals, from the largest dose, is sufficient to destroy the muscular power of the heart merely by its action on that organ. It may be safely asserted, that opium never kills by destroying the mus-. cular power of the heart; except when a large quantity is h>i jected into it or into the blood vessels. Opium received into the stomach, therefore, never induces death in this way. It is ascertained, by the experiments related in this Treatise, that the action of the strongest solution of opium applied to the heart, is merely local ; it destroys the excitability of this organ, but it produces no other effect ; the excitability of all the other muscles of the body remaining unimpaired. It is almost un- necessary to observe, that 1 here speak of the effects of opium pears to me to be the principal cause of all the confusion which has crept into the subject. I have net since found it-a son in any respect to alter, but have met with additional ciic imstar.ces to confirm, the account of the modus operandi'of opium, given in the above treatise. When I pub- lished my Essvy on Opium 1 had not seen Dr. Crump's Treatise, which appeared about the same time: and not haa ing devoted much tirr e to the subject since, I have not examined it Avith the attention it deserves ; but, as far as 1 recollect, from a hun-ied perusal of it, it contains r.r.thing winch contradicts the results mentioned in the text, but several'observa- tions tending to confirm them. * Compare a note in the 99th page of my E^ay en Opium Avith Dr. Crump's experiments on the pulse. REMITTING FEVERS. 109 when its application is confined to the heart ; if it is allowed in the course of circulation to pass to the brain, it then produces the effects which form the third class into which those of opium arc divided. The third class of the effects of opium comprehends those it produces when immediately applied to the brain : These are, when the dose is moderate, impaired sensibility, languor, sleep ; effects which are occasioned, in a greater or less degree, by all other gentle irritations of this organ, and which do not follow a moderate dose of opium till we know from the symptoms it produces, compared with the experiments which have been made on this subject, that it has been conveyed to the heart; from which, in the course of circulation, it is sent to the brain, as well as to other parts of the body. What share its action on the latter parts has in producing these effects, it is impossible to say. We have reason to believe it but trifling, because opium directly applied and confined to the brain, produces the same effects as when permitted to circulate with the blood. It appears from the experiments just alluded to, that no part of these effects is to be ascribed to its action on the heart itself. Opium applied to the brain more freely produces effects sim- ilar to those produced by other violent irritations of this organ— convulsions and death. And this is the way in which opium received into the stomach, occasions death : It is taken up by the lacteals, and in the course of circulation applied immediately to the brain. According to the quantity thus applied, it pro- duces sleep, convulsions, or death; for opium, even in the hu- man body, does not always prove fatal when it induces con- vulsions.* Of the manner in which opium acts in shortening the hot stage of intermittents, we cannot speak positively. There is reason to believe that it is chiefly by increasing the action of the heart and blood vessels. It is from this effect of opium that it is found hurtful wherever the inflammatory diathesis prevail*, in which the action of these organs is already too great. I shall seldom have occasion to say so much of the modus operandi of remedies. In this branch of medicine little upon the whole is ascertained, and nothing is more hurtful tnau hy- * In some of the experiments alluded to in the Treatise I have been speaking of, convulsions were induced on rabbits by large doses of opium, which were not sufficient, however, to prove fatal; and there are severed cases on record in which this liappencd in the human body. See casts related by Mr. Dobson and an anonymous author in the JMs. dical Museum. In all its effects on the living animal bedy, opium has much in common with other agents, but at the same time someiiili g in each peculiar to itself. It will appear (as far as I can judge) frcr.i what I sliall after- wards have occasion to say, that the same observation apphc, to every thing capable of acting on living'animals, Avhether actmg immediately en tiiu body, or affecting it through the medium of the mmd. HO INTERMITTING AND potheses intermixed with the facts which are to conduct our prac- tice. On the other hand, when any thing certain is known respecting the modus operandi of remedies, it is always of con- sequence to be acquainted with it. If our knowledge in this branch of medicine is confined, a physician is the less excusable for not being acquainted with what is known. There is no remedy whose modus operandi demands more attention than blood-letting, for two reasons ; there are few con- cerning whose mode of action we can say so much with certain- ty ; and there is none whose mode of action, particularly in fevers, has been so much misrepresented, to which misrepresentation the lives of thousands have been sacrificed. I am now to point out what is, as far as I am capable of judging from various obser- vations, which will afterwards be considered more at length, the only way in which blood-letting acts in relieving the symptoms of idiopathic fever. We know that the heart, deprived of the stimulus of the blood, ceases to contract almost instantly in the human body, and in a short time in all animals. The presence of the blood is as ne- cessary for the continued action of the heart, as the peculiar structure by which it is fitted for contraction. But every thing capable of exciting contractions in the muscular fibre, produces within certain limits more or less powerful contractions, in pro- portion to the quantity applied. In the change from a state of health to that of synocha, one of three things must take place; either the blood is driven towards the heart in greater quantity than usual, or it becomes more capable of stimulating the heart, or the heart itself becomes more irritable, that is, more capable of being acted upon, and thus contractions more powerful than those consistent with health are excited. But it has just been observed, that the effects of every stimulus in exciting the muscular fibre are within certain limits propor- tioned to the quantity applied. And Avbichever of the foregoing circumstances be the cause of the stronger action of the heart in synocha, this law stili holds good. Whether, therefore, the dis- ease originates in the blood being propelled towards the heart in greater^quantity than usual, or in its having acquired morbid properties, or in the heart having become more irritable, lessen- ing the quantity of blood must diminish the force of its contrac- tions. The following experiment directly ascertains the point in ques- tion, which is otherwise so avcII established indeed as not to re- quire this additional proof: Dr. Hales opened the blood vessels of living animals, adapted glass tubes to their orifices, and ob- served to what height the blood rose in the tubes at each systole ofthe heart; he then drew from the animals different quantities REMITTING FEVERS. 111 of blood, and observed the force of the heart diminish in propor- tion as the blood was abstracted. It must also happen, that the more suddenly the abstraction of blood is made, the greater will be its effect in diminishing the' force ofthe heart. When it is gradually abstracted, the capacity of the heart and vessels is readily adapted to the quantity of fluids they contain. If it is suddenly drawn off", the change of capacity is effected v\itTi more difficulty. The diminished action of the povvers supporting circulation, when the abstraction of blood is made suddenly, is in a great measure to be attributed to this, that the vessels not immediately adapting themselves to their contents, the quantity of blood returned to the heart, is often more dimi- nished than in proportion to the real loss of blood. It seems to be in this way, that the loss of a few ounces of blood very suddenly abstracted, often induces syncope, even in stout people who could lose six times the quantity without inconvenience were it ab- stracted more slowly. Syncope from loss of blood in general in- deed, must in a great measure depend on this cause. Did it proceed from the absolute loss of blood it would be much more fatal than wc find it. It was common with the Ancients, in a variety of diseases, to bleed the patient till he fainted. If diminishing the action ofthe heart and blood vessels, be the only effect of blood-letting in idiopathic fevers, it follows, that this remedy can only be of service in these complaints when the symptoms of synocha prevail. Till lately indeed it has been the practice to have recourse to blood-letting in all kinds of fevers. This practice was chiefly founded on mere hypothesis ; in part, however, it was founded on a fact which I shall have occasion to consider, more particularly, when speaking ofthe crises of fevers, namely, that even in well marked typhus the loss of blood has sometimes, though r,arely, proved beneficial. There can be little doubt that a spontaneous hemorrhagy has sometimes proved a favourable crisis in all kinds of fevers. And there have been some few cases perhaps, in which venesection was serviceable in typhus. I have not, however, either in the course of practice or reading met with any unequivocal case of this kind. If the state of body in some rare cases of typhus be such., that the advantages derived from venesection will more than compensate for the harm done by its debilitating effects ; nobody has yet succeeded in pointing out the means of detecting such a state. "We shall afterwards find the following observation sufficiently illustrated ; that the symptoms, which are termed critical, a flow of sweat, a hemorrhagy, a sediment in the urine, Sec. are more frequently the consequence than the cause of a favourable chanyy in the complaint; and we may in vain induce such symptoms, if we counteract that favourable change which often occasions their spontaneous appearance. It would be difficult to point out any other error in medicine, 112 INTERMITTING AND which has proved equally hurtful with the hypothesis, that led physicians to regard certain symptoms, which frequently attend the change from fever to health, as the sole cause of that change. From which source arose, among other hurtful fcpecies of prac- tice, the indiscriminate use of blood-letting in this complaint. SUCH is the plan of treatment during the paroxysm of an intermittent, and, as far as I can judge, the sum of what is known respecting the modus operandi ofthe principal means employed at this period. Wc are novv to consider the remaining general cUvision of the treatment of intermittents) namely, that during the remission or apyrexia. SECT. II. Of the Treatment of an Intermittent during the Apyrexia. THIS is the most important part of the practice in a^ucs, and that which, strictly speaking, can alone be regarded as cura- tive. The indications in the apyrexia or remissions are, to restore the patient's strength and to prevent the return ofthe paroxysm. The first is answered chiefly by an attention to diet and exercise j the other by medicines. 1. Of the Diet and Exercise during the Apyrexia. This part of the treatment I shall consider at some length be- cause it is that which is most generally neglected, and notwith- standing its simplicity, least generally understood. Wherever there is much of the inflammatory diathesis, the patient's diet must be such as tends to counteract this habit of body. His food should consist of milk and vegetables, and even of these he should not be permitted to eat plentifully, if signs of plethora are evident. A spare diet is one of the few means we have of overcoming habitual fulness. While there is any ten- dency to inflammation in the system, fermented liquors must be avoided ; the patient's drink should consist of plain water, or some mild vegetable decoction. When, on the other hand, much debility prevails, he must be allowed as full a diet as his stomach will bear. It often happens in debilitated states of the system, that the stronger kinds of an-* imal food occasion a degree of irritation capable of exciting temporary fever. Beef, mutton, Sec. ought therefore to be avoid-1 ed; veal, lamb, and chicken, when the powers of digestion are not much weakened, Avill be found equally nourishing, and irri- tate less. Upon the v/holc, aii that is necessary in this case is, to chuse that kind of food which affords most nourishment, with least irritation. The same rule applies to the drink: When the REMITTING FEVERS. Ill strength is much reduced, it should never consist of pure water, and in no cas&of any mixture containing distilled spirits, except where fermented liquors, which have not been distilled, cannot be procured. The best drink in cases where debility prevails is wine, particularly port, or, Avhat is still better, claret, diluted with Avater ; the quantity is easily regulated by attending to the con- stitution and h&bits'of the.patient, and the* effects which the wine produces. Of the fermented liquors of this country, porter is ;:ercruliy found the best. This, or any others Avhich the patient pre. ers, is alw*»ys to be recommended in preference to any kind of distilled spirits, whether diluted or not. While the digestive powers remain but little impaired, these few regulations arc all that are necessary respecting the diet du- ring the apyrexia of intermittents. But it is not uncommon for a considerable degree of dyspepsia to supervene in these fevers, and then a more particular attention to diet becomes nccessaiy. Acescent and oily articles of food, with a large proportion of liquid, compose the diet most apt to injure digestion. The op- posite to this diet, therefore, is that which agrees best with dys- peptics. I have just had occasion to observe, that the flesh of old .'nimals irritates more during digestion than that of young. By this, however, it is not meant that the latter is of more easy digestion. Just the contrary of this is true. The flesh of old a*iiuial'i in general is more easily digested than that of young, but irritates more while digestion goes on. Nearly the same may be said of the food derived from the Avhole animal world, compared with that Composed of vegetables. The former is con- stantly found more irritating,, more apt to induce fever ; the latter more difficult to digest. We must attend, therefore to the state of the patient; and in particular to the tendency to fever or dyspepsia, and regulate his diet accordingly. Where it is our view to obviate the symptoms of dyspepsi.i, a diet composed of the flesh of old an;rials, and bread toasted till it is hard, will be found the best. All kinds of soups, gravies, and fvsh vegetables should be avoided, and every thing into the com- position of which butter, or any other oily substance, enters. The same may be said of all hard animal substances, salted and smoked meat, cheese, &c. The harder animal substances are, the more difficult are they of digestion. This is not true of vege- tables. There is perhaps no vegetable substance so easy of di- gestion as a hard sea-biscuit, provided it be properly masticated. The tough, thready, and membranous parts of vegetables are of most difficult digcsti'in ; next to these, the cold vegetables cat raw, melons, cucumbers, Sec. Before a dyspeptic can shake^on? his complaints he mu.it learn to j-csist the gratification of his taste, and he must endure this mortification not for days or weeks, but many months, or e\ en years, if he is resolved not to be tor- Voi.. I. P 114 INTERMITTING AND mented by constant returns of the complaint; for when dyspep- sia is occasioned by agues, or other lingcrins, complaints, it often continues to harrass the patient long after every symptom of the primary disease is removed. There is much difference of opinion respecting the proper drink in dyspeptic cases. I have just had occasion to observe, tliat the less the diet in this complaint consists of liquid the better. But there is generally present a considerable degree of thirst, and a certain quantity of fluid is necessary. The general opinion is, that every land of distilled spirits, as less acescent, is prefer- able in dyspepsia to any ofthe fermented liquors, which have not been distilled. The truth is, that neither the one nor the other is a proper article of diet in dyspepsia. They are only to be given when it is of more consequence to support the patient's strength, than to adhere, in every respect, to that diet which is best suited to a weak stomach. But of the two, I have uniformly found (and I am acquainted Avith other practitioners, who have made this disease a particular study, that are of the same opinion) that fermented liquors, which have not been distilled, particularly the red wines, are less hurtful in dyspepsia than any kind of spi- rits, and that the more diluted they are, provided the patient does not take a very large quantity of fluid, they are the less in- jurious. Wherever the patient's strength is not much reduced, the best drink in dyspepsia, is thin vvater gruel : this is neither very acescent, nor capable of hurting the digestive organs, by applying to them too strong a stimulus; and its mucilaginous property defends the stomach and bowels against any irritating matter they happen to contain. The hurtful cfleets of taking the drink very warm in dyspepsia are generally admitted ; but most practitioners are not aware, that eqir.d harm is done by taking it very cold. Even ice is sometimes prescribed as a tonic in cases of indigestion ; which I have known to be the means of inducing this complaint. There are many dyspeptics who cannot, without injury, take their drink of a temperature lower than 80°; and there is no case of dyspepsia in which its temperature should be under 50°. Whatever be the quality of the food, the dyspeptic must be restricted with respect to its quantity ; particularly the quantity which he takes at one meal. This caution is the more necessa- ry, because the appetite in dyspepsia is often morbidly increased. Nor is it proper for the interval between meals to be long. I do not know any rule of more importance in this complaint) than to eat frequently and not much at a time; neither to permit the stomach to remain long empty, nor to oppress it with a load of food. Such are the general observations by which the diet, during REMITTING FEVERS. IIS the apyrexia of intermittents, is regulated. It would be tedious to enter into particulars which every one's reflection must sug- gest to him. The exercise both of the mind and body, at this period, also demands particular attention. The degree Of these must be suit- ed to the strength of the patient. The different kinds of bodily exercise may be arranged under three divisions. That in which the body is moved by its own exertions, as in walking; that in which it is moved by any (-ther power, as in the various modes of gestation ; and that in which the circulation is promoted without moving the body, by friction for example, or merely by pressure. Intermitting fever may induce such a degree of weakness, that friction may be the only kind of exercise which the patient can endure without fatigue. This, however, is seldom the case when the intermissions are considerable; but wherever the strength is much reduced, although the patient can bear a little of some rougher exercise, frictions are always useful. Friction is the principal exercise among the higher ranks of some Asiatic nations, and it was used both by the Greeks and Romans after they became luxurious. As the total want of exercise is not more pernicious than that which occasions fatigue, the different kinds of gestation, even after the patient has recovered a considerable degree of strength, are often found preferable to those exercises, in which the body is moved by its own exertions. The gentlest kind of gestation is sailing, which often proA'es serviceable in all cases of debility, and has been particularly re- commended in weaknesses of the stomach and bowels.* Next to sailing, the gentlest kind of exercise, commonly pre- scribed, is the motion of a carriage, and in those who are too weak to ride on horseback, it is often attended with the best effects. But in such climates as our own the patient must either be confined in a close carriage, or run the risk of being chilled. As a substitute for a carriage, but inferior to it, swings and spring chairs are frequently recommended with advantage. But none of these modes of exercise are equal to that on horseback, when the patient is strong enough not to be soon fatigued by it. It is particularly suited to those cases in which dyspepsia prevails. Of all kinds of exercise, Dr. Whytt observes, riding on horse- back has been justly esteemed the best.f Sydenham is extrava- gant in his praise of this mode of exercise, and particularly re- commends it in hypochondriacal and hysterical disorders. Ri- ding, he observes, is preferable to walking, as it shakes the body more and fatigues it less. It is to be remembered, however, that * tee Dr. Gilchrist's Treatise on the Use of Sea Voyages in Medicine. | S;v lm Treatise on Nervous Complaints. U6 INTERMITTING AND fcny rough exercise, and particularly riding on horseback, Soon after meals, disturbs digestion. Notwithstanding what has been said of riding on horseback ; after the patient has acquired sufficient strength to walk for an hour or two without fatigue, this mode of exercise is found upon the v hole preferable to all others ; it is attended a\ 1th a more uni- form and general exertion of the muscles, and from the valvular structure of the veins is better fitted to promote circulation. It is often of service to combine the two last modes of exercise ; riding on horseback being particularly adapted to restore the tone of the stomach and bowels, while walking is better fitted to strengthen the system in general. In cases of debility we must regulate the exercise of the mind as well as that of the body. When the latter is debilitated, the former in general is languid and listless. This state of mind is more or less overcome by a proper degree of bodily exercise, but the occupation of the mind itself is the best means of removing it. The maxims which regulate the degree of bodily exer- cise, are also applicable to that of the mind. The great rule is to occupy without fatiguing it. Any study which fatigues is in- jurious, and the constant languor of a mind wholly unoccupied is no less so. Wherever the debility is considerable, the mind should be occupied by amusement alone ; and even those amuse- ments which interest the fceiings much, or occasion any consid- erable exertion of mind, may be hurtful. When, on the oiher hand, the patient has recovered a considerable degree of strength, a moderate attention even to business is found serviceable. How- ever varied our occupations are, if they tend only to present "gra- tification, they soon become insipid. The mind must have some- thing in view, some plan of bettering its* condition, in order/ to r.nest the attention for any length of tin.c. I kno.v cf nothing of greater advantage to paliei.ts in a debilitated habit of body, than the conversation of friends who con it ,,i.tiy present to them the fairest side of their future pfospecta. The time of d„y, at which either the lr.ind or body is exercis- ed, is also a mc-.tter of considerable importance. Towards tho evening every hind of exertion becomes irksome, and con- sequently hurtful. Besides, in those who are debilitated, a degree of fever (probably the consequence of the unavoidable ir- rii..i„.isipplied to the body throughout the day) comes on at this time, which iscdy to be relieved by iepcse ; going early to Ltd, therefore, is of much ccnr.equentee in such cases. Exposure to the night air is particulci !y hurtful to people in a debilitated state of body. This seems partly o-.rincr to the cause just mentioned, that all kinds of exertion are huiu-il towards the end of the day, partly to the dampness cf the night air, and partiy perhaps to some less evident ci.use. But although it is of consequence for the debilitated to go car- REMITTING FEVERS. 117 ■ly to bed, there arc few things more hurtful than remaining in bed too hug. After the degree of strength, of which the present Mate of the system is capable, is restored by sleep, any longer continuance in bed tends only to relax. Getting up an hour and an half earlier in the morning often gives a degree of vigour which nothing else can procure. I know people whose feet con- stantly become cold and damp if they remain in bed a few hours awake in the morning. It is remarkable, that the same- effect is not produced, hoAvcver long they remain in bed, provided they are asleep. For those who are not grt a;ly debilitated, the best rule is to get out of bed as soon as they awake in the morning. This at first perhaps may be too early, for debilitated habits re- quire more sleep than people in health ; but the exertion of ri- sing early will gradually prolong the sleep on the succeeding night, till the quantity which the patient enjoys is equal to his de- iiiand for it; thus, what ut first sight may seem a paradox, getting out of bed early in the morning is one of the surest means of prolonging the time spent in sleep ; an effect 1 Lave often -known" it have. Lying late is not only hurtful by, the relaxation it occasions, but aho by occupying that time of the day at which exercise is most beneficial. As soon as the patient rises, he should have breakfast, because exertions of every kind are improper while the stomach is empty ; nor are they proper during the first part of digestion, being apt to impede it; they ought to be delayed till about an hour after breakfast. From this time to two or three o'clock is the proper time of the day for the exercise both of the mind and body ; after this the debilitated should lay aside every occupation \\ hich tends to fatigue ; to which the exertions during the former part of the day will sufficiently incline them. In every circumstance respecting diet and exercise much at- tention must constantly be paid to the patient's age, habits, and inclinations. Old people are less subject to that diathesis which disposes to inflammation, than the young; in them debility is most to be dreaded, and when it occurs is removed with most difficulty. We seldom find occasion therefore to recommend a Ioav diet to them. Wine, it has been said, is milk for old men, and this proverb contains.one of the be6t maxims in medicine. In old age also, ivpose is more necessary, and exertions of every kind are less beneficial, and more apt to be hurtful. With respect to diet, however, no general rule can be laid down ; in old people we sometimes meet with the inflammatory diathesis, which must be treated in the manner just pointed out, but with the more caution the older the patient is. In young people, on tlie other hand, we often meet with a debilitated state, of the system, which is more easily counteracted indeed at this period "of life, but which even in youth often baffles all our endeavours. 118 INTERMITTING AND In both old and young the inflammatory diathesis is most apt to occur in an early stage of the disease ; the frequent repetition ofthe paroxysms tends to overcome this diathesis and to produce debility ; a poor diet, therefore, is generally hurtful in protract- ed cases. The patient's desires also lead us to form indications respecting his diet and exercise. When the remissions are but imperfect, he has little or no desire for food or exercise, and nothing could be more hurtful than to force him in such cases to take either the one or the other ; any inclination to sleep, during the inter- mission, should be encouraged. Sleep restores the strength after the debilitating effects of the last paroxysm, and affords new vigour to combat that which succeeds. On the other hand, when the patient has any inclination to eat or walk about, we are not to insist on his keeping his bed, or abstaining from food, during the intermission. The necessity for sleep or food is best deter- mined by the patient's feelings ; and nobody but himself can judge of them. Longings for particular articles of food, if not very improper, should be indulged, since the irritation they occa- sion, when not gratified, does harm. It is common, in all kinds of fever, for the patient to long for fresh fruits ; which tend both to refresh in typhus, and allay the inflammatory symptoms of synocha. During the intermission of agues, however^ they prove hurtful, When the patient is troubled with dyspepsia, or bowel complaints. In regulating the diet, during the intermission, some attention should be paid to the season of the year. In spring it has been observed, the inflammatory diathesis prevails more frequently than in autumn. In tlie latter season, especially at its commence- ment, we dread debility ; fevers are then more apt to become malignant. The warmer and moister the season is, the greater reason is there to dread debility. The inflammatory diathesis is most apt to prevail when the weather is cold and changeable. We must attend also to the nature of the prevailing epidemic When it is accompanied with inflammatory symptoms, the patient should avoid animal food and fermented liquors ; when accom-' panied with those symptoms Avhich have been termed putrescent, every thing which debilitates must be shunned, and as full a diet prescribed as the state of the patient admifs of. The most important part of the treatment in agues still re- mains to be considered, namely, the medicines employed du- ring the remission or apyrexia. 2. Of the Medicines employed during the Remission or Apyrexia. These may be divided into two classes : such as are exhibited during the whole, or at least a great part, of the apyrexia ; and such as only prove beneficial when the paroxysm is expected. REMITTING FEVERS. 11* In the first place, of those exhibited during the whole or a great part of the apyrexia. Of all the medicines, recommended in intermittents, none has been so generally employed as the Peruvian bark. On this me- dicine indeed the generality of practitioners wholly depend for the cure of these fevers. It therefore particularly demands at- tention.* This valuable medicine is the bark oi* a middle sized tree, a native of Peru. The circumstance which led Europeans to pay attention to the Peruvian bark, was a remarkable cure performed by it on the countess del Cinchon, the Spanish viceroy's lady, in the year 1640. It is said, that the Indians were not ignorant of its virtues as early as the year 1500. In 1649, a Jesuit brought a considerable quantity of it into Italy, which was distributed by the fathers of that order at a high price over a great part of Eu- rope, from ivhich circumstance it got the name of Jesuit's bark; and, about the same time, the cardinal de Lugo imported a quan- tity of it for the use of the poor at Rome. " When first intro- " duced (Dr. Cullent observes) it was found to cure intermittents " very readily ; but whether it was that a medicine of more " seeming efficacy Avas at the same time brought into Europe, " or whether timid practice lessened the dose, it went out of cre- K dit, and was not till 30 years afterwards restored by Talbot." The bark is an astringent bitter, with some degree of aromatic flavour; to none of these qualities, however, can its power of curing intermitting fever be attributed, since no combination of astringents, bitters, and aromatics, is found equally effectual. A variety of prejudices respecting the bark prevailed for along time after its introduction into Europe, and prevented its general use. The more ancient of these do not even deserve to be men- tioned, such as, that those who use this medicine die within a year, or according to others Avithin seven years, that it is particu- larly pernicious to fat people, &c. The prejudices which in many places still interfere to prevent the free employment of this me- dicine arose chiefly from the nature of the fevers in which the bark is recommended. Intermitting fever, it has been observed, is often followed by obstructions of tlie \is'cera, dropsy, &c.; these, which are the consequences of the disease, were, and in some places still are, attributed to the bark.l * This medicine is mentioned by authors under a variety cf appella- tions, chiuccna, chinachina, chinch'ina, kina kina, kirkina, quina qnina, quinquina, puhiscomitissx, gentiana indica, anliquartium Peruvianum, jesuiticus pubis, cardinaf de Lugo's powder, &c. t See his Materia Medica. X It is now well ascertained, however, that there is no foundation what- ever fur tliis opinion. Dr. Millar (Account oi* tlie Diseases most prera- \Q0 INTERMITTING AND Although almost ail practitioners at present employ \hc i ark in agues, at least when they arc protracted beyond a few parox- ysms, there is some difference of opinion concerning the pcrird of the disease at which it ought to be exhibited, the preparation ofthe patient, &c. We deter;nir.e when and how the bark is to be given by at- tending to the following circumstances. 1. The period ofthe disease. 2. The nature of the symptoms, particularly the presence of the inflammatory diathesis, or debility. lent in Britain) declares it his opinion, contrary to what he once thought, that the fever, and not the bark, is the cause of the obstructions and di on' sjes which frequently supervene on agues, and that the bark is the bcVt means of preventing these afLctio ;p. Ur. Jackson (Acccuntcf the Dis- eases cf Jamaica) lemarks, that he always found dvsenterv, dropsy, and visceral obstructions, most common Avherethe bark was most sparinp-jy. employed. When the ague, Dr. Lind observes, was stopped by the bark immediately after the firs': or second lit, as in my own case and that of 200 of my patients, neither a jaundice nor dropsy ensued ; whereas when the bark could not be administered on account of the imperfect remssions, of the fever, or when the patient had neglected to take it, either a dropsy, jaundice, or a constant head-ache were the certain consequences, and the degree of violence was proportioned to the number ol the preceding fits. or to the continuance of the fever. The bark indeed is by many regarded as among the best means we have of removing such affections, when they are tlie consequences of agues. Dr. Brocklesby (on the Diseases of the Army) recommends it in cases of visceral obstruction after the use of mild and repeated emetics and cathar- tics ; and Dr. 3',rack (De Febribus Intermittentibus) remarks, that lie has found the bark more powerful than any other medicine in removing indurations of the spleen, and has observed" it successful in the dropsical affections which supervene on intermittents. It is also a prevalent opinion in many places, that agues cured bv the bark more frequently return than those which leave the patient after'run- mng their full course. But Torli (Therapeutice Specialis) has justly ob- served, that if fevers cured by the bark sometimes return, those removed by other means are no less apt to do-so; and when overcome bv the ef- forts of nature aloue, they frequently attack the patient a second time or oftener. bince these fevers, he continues, in whatever manner they are cured have a tendency to return in autumn, but not in spring ancl tne beginning ot summer, we must, with Morton, conclude that tlie dispo- sition ot the fever, and not the nature of the remedy, is in fault. Num- berless observations might he quoted to die same purpose In short, amidst all tne prejudices e;attained against tlie bark, wherever it has been fairly tncu, it has proved both a safe and successful medicine in intermittents. Never was there any medicine, D'Aquiri observes, known to cure fevers so qu.ckly, and whh so much safety. The authority of Sydenham i« not to be, overlooked. « Vere affrmare possum non ob- stante tarn vulgi quam perpaucorum e doctig prej.iclicio, me nihil mali rhgnsaccidesse ab ejus usu vuhsse unquam, a el cum ritione susiicare "potuisse.' It other authorities be required, 1 might here repeat the names ot almost every author i have liad occasion to mention bo gene- rally indeed is the innocence of the W-.vk admitted and confirmed bv so extensive an experience, that nu authority against it can now claim any REMITTING FEVERS. 12i .1. The climate, and the season ofthe year. 4. The age and habit ofthe patient; and 5. The nature ofthe epidemic. 1. Of the period of the disease, most proper for the exhibition ofthe bark. Where the debility is great, the symptoms consequently alarm* ing, and much danger to be apprehended if the fever again re- curs, especially where the apyrexia is short and imperfect, it is often adviseable to begin to give the bark about the end of the hot fit; for were it delayed till the remission takes place, It might be Impossible to throw in a sufficient quantity before the succeed- ing paroxysm. And if the patient be much reduced, and the symptoms termed putrescent have made their appearance, the bark, as I shall presently have occasion to observe more particu- larly, is proper after the remissions haA'e become so slight as to be hardly perceived. The general plan in intermitting ancl re- mitting fever, however, is not to give the bark till complete apy- rexia, or an evident remission of" the symptoms, u.kes place ; it is then given in various doses and at different intervals,* as the state of the complaint requires. There has been some dispute respecting the best time of the apyrexia for the exhibition of the bark. Many give it immedi- ately after the paroxysm, and at interval till the fever returns ; others only during a few hours before the paroxysm. We must determine in Avhich of these ways the bark is to be exhibited, by attending to the duration of the apyrexia, the quantity of bark required, and the quantity which the stomach is capable of re- ceiving in one dosc.t "When the apyrexia is short, and the quantity of bark required considerable, it must be given immediately after the paroxysms, * While the intermitting form remains distinctly marked, it is univer- sally admitted that the exhibition ofthe bark during tlie cold or hot fits is itnpr.Tper. Dr. Fordyce made a trial of the bark during the hot fit, and found that it both increased the length of the paroxysm, and lcndered the crisis less perfect. Dr. Cleghorn also remarks, that when the bark was given during the paroxysm, tlie patient died; but he recovered often after his* case seemed desperate, if the remissions were seized for the exhibition of this medicine. f While the prejudices against the bark were prevalent, it was gen- erally exhibited in the former of tbase ways, in all cases. The doses were small, and the intervals at which they Avere given long. Sydenham disapproved of giving the bark in large doses, and generally endeavour- ed t'i seize long intervals for throwing it veiy gradually into the body. 11 : recommends mixing an ounce of bark with svrup of roses, and giving tli-; patient the size of a nutmeg morning and evening, on the days of in- rrmission, until the »v mle quantity is finished. The same quantity was vjie.ued in 14 days, which Avas given a third time in the same manner Wnile such was tlie m >,le of prescribing the bark, we cannot be surprised th it it was not found very successful. V Ol. I. Q, 122 INTERMITTING AND and continued till the return of the succeeding fit at longer or shorter intervals, according as the case is more e observed in confirmation of what was said ofthe proper period <" >r blood-letting in these fevers, that he particularly recommends the hot fit fir this purpose. He generally gave a cathartic immediately after the blot id-letting. From the observations made respecting the treatment du- ring the paroxysm, the propriety of this mode of practice appears doubt- ful. Titere are few authors who treat of intermittents, who have not had occasion to make observations similar to those of Sir John Pringle.—Dr. Donald Alunro, in particular, gives nearly the same account of the remit- tents which prevailed among the soldiers en the Continent—When the bark had failed on several trials, Dr. Rush observes, one or two moderate blood-lettings,general!}" secured its success; in these cases, he adds, the pulse is full and a little hard, and the blood sizy. The bark is always un- successful, he justly remarks, Avhen blood-letting is necessaiy, and he says he has known many instances in which pounds of this medicine had been fiven without effect, which yielded readily after ten or twelve ounces of lood were taken away. Dr. Rush thinks that blisters often serve the purpose of blood-letting in these cases; but they are not to be depended upon. Hoav different a mode of treatment is to be pursued, when our practice in agues is not incumbered by the presence of the inflammatory diath *sis, will appear from comparing what is said by these authors, Avith what Dr. Jackson says of the fevers which prevailed among the troops in America. " Time, (he observes) is not to be spent in frivolous prepara- " tions, or diseases attacked wiih feeble remedies, when the health of " soldiers is concerned." la the autumnal months, when signs of malignity and danger were present, he generally seized the first intermission for exhibiting the bark, without premising either vomiting or purging, even where the bowels were loaded. He gave two drams tor a dose, and re- peated it every two hours, while the lever was absent. Two ounces, he observes, taken in the space of eight or ten hours, were often more effect- ual than double the quantity in small doses and at long intervals. * Dr. Cleghorn seldom gave the bark in tertians till the fifth day. From the paroxysm which took place on that day, lie judged whether or not the bark was necessary, and in what quantity it ought to be given. If this paroxysm, namely the third, was not longer and attended with worse symptoms than the second, if ihe patient preserved his strength, and if a lateritions sediment appeared in the urine, he often ventured to trust the cure to nature. Ashe judged from this paroxysm of the future treatment of the disease, he was careful to premise such medicines as tended to mo- derate the complaint, and prepare the body for immediately receiving die bark, in case the symptoms of die third paroxysm proved it necessaiy. During tlie first three or four days, therefore, he ordered evacuations. It was his custom, we have seen, to take away a little blood at tlie com- mencement of the disease, if the state of the patient admitted of it; and he never failed to clear the primss vix of any irritating matter which they happened to contain at tills period; and to these means alone the com- 124 INTERMITTING AND continuance of disease always tends to overcome the inflammatory diathesis; thus wc constantly find, as was observed on a former occasion, that hoAvever well marked this diathesis is at the com- mencement of fever, it always disappears in its progress. On this account practitioners have found, that many intermittents yield to the bark with more case, after they have run through several paroxysms, than at their commencement.* Many, from this circumstance, have been led to lay it down as a general ride, that the bark is not to be given at the commence- ment of agues ; ancl this rule they found the more useful, at it was often necessary to clear the prim* vuc before its exhibi- tion. Such appear to be the sources of the prejudice against giving the bark at the commencement of intermittents; for a prejudice it certainly is, when made a general rule. If confined to those cases in which the inflammatory diathesis prevails, it is the result of universal experience. We are not, however, in such cases, as Dr. Brocklesby and others recommend, to delay the use of the bark till the continu- ance of the disease has overcome this diathesis. This would of- ten be attended with the worst consequences. We are only to delay it till by the proper use of the means above pointed out, we have corrected that state of the system which renders the exhi* bition of the bark improper. There is nothing in the nature of intermittents, except their being frequently attended by the in- flammatory diathesis, which prevents the use of the bark at every commencement, that is, after the first paroxysm. plaint sometimes yielded. Rut if the third parcxvsm was the longest and most severe that had happened, if it was attended with any dangerous symptoms, if the sick became giddy, feeble, or langi Ul, without delay lie had reccur.se to the bark. As soon as the sweat ceaied to Aoav, he order- ed two scruples or a dram of it to be given every two or three hours, or every hour and an half, so that five or six drams mie-ht be taken before next day at noon. It is neces sary, he remarks, that a considerable quan- tity of the bark be given at this period ; since after it, the fits are often redoubled, so that we have not a proper opportunity of giving the medi, cine. It is to be remembered, however, that Cleghorn practised in the mild climate of Minorca. In general we shall ind that the exhibition of the bark t.ioi.d not be delayed so Uig as he recommends, particu- larly in autumnal agues. * * * When the patient was athletic, Dr. Brccklesby observes he allowed the fever to i tin on for a little, before he gave the bark. Giving ti-e bark too early, lie remarks m athletic ha!:-, produced much' pam ot the head yellowness ofthe eyes, and sometimes cu.timied fever.—Hillary also ob- serves, that he has treouently seen the early u,e cf the bark render the iZ°^^ ?% Tr mTf^- Breck'-'^r on the Diseases of he Army, and Hillary s Account of the Diseases of;;- ,badoes In those cases where the tendency to inflammatory symptoms prevents us giving much of the bark, Dr. Brocklcby recommends giving; JSS doses cf i with myrrh, Miakeroot or some other such medicine tillI the inflammutory diathesis is sumaer.tiy remov ,d to ud.-.a: cf eivini m? bark ui laivcr doses. *»""'$ *-uc pais REMITTING FEVERS. 125 "Wherever the pulse' is feeble and quick, and the strength greatly reduced, the early exhibition of the bark is indispensable.* Nay it appears, from the observations of Mr. Clark, just quoted in a note, as well as those cf others, that where the symptoms of typhus are well marked, the bark is to be exhibited even during the paroxysm.f While the inflammatory diathesis is present, the bark proves the more hurtful, the more the fever shows a tendency to become continued. The use of the bark in these circumstances indeed often renders it so. The contrary of this obser\ration is true of the cases in which debility prevails ; in these, provided the remissions are still dis- tinctly marked, the greater tendency the fever shows to become continued, the greater is the quantity of bark required ; and the more the patient is capable of receiving, the greater tendency the fever shews to resume the intermitting form. These obsen'a- lions, the truth of which must strike every one who peruses with care the works ofthe original authors on the subject, have been frequently overlooked, and much confusion has arisen from wri- ters attempting to lay down, as generally applicable to the treat- ment of agues, the maxims of practice, which they found suited to the particular cases which fell under their own observation. In the treatment of agues, more attentioa has been paid than seems proper, to the state of the stomach and bowels. It is a very prevalent opinion, that while the stomach and bowels are loaded, * Di\ Brocklesby obFerves, that Avhen the patient was Aveak and irri- table, he gave the bark immediately, and then did not even wait for the Erevious exhibition of emetics and cathartics, whatever the state of the owels might be. This part of Dr. Brocklesby's observations is well illustrated by those of Mr. Clark, on the Diseases in long Voyages to hot Climates, which in a striking manner point out the propriety of having immediate recourse to the bark wherever there is much debility ; ana particularly if the symptoms peculiar to typhus make their appearance. " If the remissions are distinct, (he observes) tlie bark will have a more *' speedy effect; but even although the disease, (wliich was alwavs at- " tended with symptoms of debility) is continued, bv its use, it is ef>ectu- " ally prevented from growing dangerous and malignant." When the patient Avas too weak to receive the bark in powder, be had recou ; to the decoction, and when even this could not be retained alone, he Ave along with it a large dose of solid opium ; for the patient's lite sc -ed to depend on the exhibition of the bark. In such cases he found -cu benefit from giving wine along with tlie bark. This is not onlv serv abk- by supporting the patient's strength, but also by rendering the jar!: more effectual; for m very debilitated states of the si stem mr.ch'.avcir quantities of the bark are required, to prevent the return of the fever! f The bark (says Raymond) should be given during the paroxysm, with much acid, particularly the vitriolic acid, when the patient has die facics h>procratica, when he is subject to syncope or coma, when his pulse intermits, and his breathing is stertorous, and then, re adds, it is the best of all remedies, and often rescues the patient from the very i' iavs of death. See Raymond's paper on the Intermittents cf Mcttiiu- urgh, in Baldingcr's Syllogc Opusculorum. 136 INTERMITTING AND whatever be the state of the symptoms, the bark ought not to be exhibited. Intermittents, Dr. Mead* observes, are not safely cured by the bark until the prim* viae have been cleared, and al- most every writer on the subject makes similar observations. When the symptoms are not urgent, and especially when there is any degree of the inflammatory diathesis, if there is reason to suspect the presence of irritating matter in the stomach and bowels, it is proper to delay the use of the bark till after the op- eration of an emetic and cathartic. But in urgent cases, and where there is no inflammatory dia- thesis, the bark ought not, to be delayed an hour on account of the state of the stomach and boAvels. Nay it even appears from the observations of Dr. Jackson,t Dr. Donald Munro, and others, that actual vomiting and purging should not induce us to delay the exhibition ofthe bark, when the state of the fever requires it. " I may remark," says the former of these authors, " that the " bark was often rejected by the stomach, and in some cases past " oft' almost instantly by stool, yet the course of the fever seem- " ed to be no less effectually checked by it than when such effects « did not occur."—" In violent cases,"' Dr. Donald Munroi ob- serves, « where it was necessary to give the bark before emetics " and cathartics could be exhibited, I often gave it along with a ca- " thartic, and found that keeping up a catharsis did not prevent the « bark curing the agile." From these and similar observations it appears, that the remark of Dr. Millar|| and others, that tho exhibition of the bark can be of no service while a diarrhoea con, tinues, is unfounded ; or at least not to be admitted in its full extent. From the same observations also, we must infer that the com- mon practiced givjng large closes of opium, and other medi- cines, to allay spontaneous vomiting and purging, in order to exhibit the bark early in urgent cases, is often improper; since the continuance of these will not prevent the effects of the bark, if it can-be made to lie on the stomach only for a short time, and the dose be constantly repeated ; and by checking them we lay up a fruitful source of irritation, which never fails to increase tlie fever. In less urgent cases, where the immediate exhibition of the bark is not necessary, if spontaneous vomiting ancl purging occur, the proper treatment is to promote these evacuations by diluents till the primae vi* are sufficiently freed from the irritating con- tents ; and then to allay the commotion excited by opiates, be- fore we order the bark. * Monita et Praecepta Medica. t See his Account of the D'iseases of Jamaica. X See his Account of the Diseases of the Army. U See his Work on the Diseases most prevalent in Great Britain. REMITTING FEVERS. W ' 3. The climate and season of the year influence our practice in the use ofthe bark. As in sultry climates, diseases run their course rapidly, and the change from a state of increased excite- ment to that of debility, in the fevers of such climates, is often very sudden ; evacuations, although they seem necessary at their commencement, often pro\re fatal by increasing the subsequent debility. In these climates therefore, when the symptoms are not very urgent, but a full pulse and other signs of the inflamma-* tory diathesis present, instead of preparing the patient for the bark by blood-letting,* it is often sal's r to defer the febrifuge till a few paroxysms of the fever have removed this diathesis, and at most to promote this effect by cooling laxatives, and diluent clysters.f In this, as in many other instances, much depends on the dis- cernment of the practitioner, even after he is made acquainted with every circumstance which ought to influence his judgment. When the inflammatory symptoms run so high as to bring the life of the patient into immediate danger, we must in every part of the world have recourse to blood-letting. And we are also to remember that the continuance of violent excitement, even where life is not in immediate danger, is itself a highly debili- tating cause, and will often debilitate more than a Avell timed blood-letting, which relieves it.i * Dr. Lind,irthis account of the Remitting Fever of Bengal, relates a remarkable instance of the bad effects of blood-letting in tropical climates, even when employed with caution. A patient of his, convinced that tlie operation Avould relieve him, insisted on being bled. Dr. Lind in vain dissuaded him from it. Only five or six ounces were taken from him, the consequence of which was, that he lost his strength, and in less than an hour, during Avhich he made his will, he was carried off by the next fit. Dr. Lind candidly adds, " a certain able phvsician is of " opinion that if this man had been bled during the hot fit, and not be- " twecn the fits, it might perhaps haA'e been attended with a happier " issue." Mr. Badinr.ck and the surgeon ofthe Ponsborne, he observes, bled each of them tivopatients; each lost one. f It is on account of the tendency to debility in the fevers of sultry cli- mates, that Ave find authors insisting particularly on the necessity of hav- ing recourse to the bark in these fevers at an early period. I ha\'e already quoted the observations of Dr. Jackson. The early use of the baric, Dr. Brocklesby observes, is particularly necessary in the fevers of the West Indies, especially in those which appear in die rainy season. It was observed, when speaking of the causes of intermittents, that it is during the rainy season of suliry climates that the most dangerous fevers prevail. X la a treatise just alluded to, Dr. Lind on the Remitting Fever of Bengal, we find an instance of the good effects of blood-letting when ju- diciously employed even in this dreadful fever. " The first mate," he ob- uerves, " complained of a violent pain in his head with a full and hard " pulse. I took about four or five ounces of blood from him, and he was " not only greatly eased by it for the present, but his recovery was not " in the least checked by it, nay, the fever after it became less irregular." In such cases the utmost caution is required ; for even where the inflam- matory symptoms appear considerable, the sudden sinking after blood- letting is often wonderfuL 138 INTERMITTING AND In cold climates, fevers of all kinds are more generally accom- panied with inflammatory symptoms, and none more frequently than agues ; evacuations previous to the use of the bark, there- fore, are more necessary in these climates, and must often bo carried to a greater extent. It is fortunate that in such climates they are not attended with the same danger. Even the season ofthe year in the same climate influences the exhibition of tlie bark. In vernal agues, iYom the greater preva- lence of inflammatory symptoms, evacuations previous to the ex- hibition of the bark are more necessary than in autumnal inter- mittents ; and they are also safer. It is in the latter season that debilitating causes are most apt to change these fevers to the continued form, and the early exhibition of the bark is less fre- quently improper, and more generally necessary. 4. In prescribing the bark we must also attend to the age and habit ofthe patient. If he be young and plethoric, the pulse will often be full ; and evacuations, previous to giving the bark, wiil frequently be found necessary. When the patient is old or re- duced by Ioav diet, previous disease, or any other cause ; it is sel- dom necessary in agues unaccompanied by any tendency to local inflammation, to prepare him for the bark in any other way, than by a gentle emetic and cathartic when the stomach and bowels, happen to be loaded. In these cases the bark should be given in considerable quantity during the first or second remission, not only because in debilitated habits the continuance of the fever if most to be dreaded, but also because wherever there is much de- bility a greater quantity of bark is required for the removal of the fever. It is to this circumstance, together with the power of ha* bit, that we are to attribute the obstinacy of protracted cases. 5. One circumstance to be constantly kept in view in the treat- ment of agues, is the nature of the prevailing epidemic. When it is frequently attended with local inflammation, or when the in- flammatory symptoms of the fever itself run high, the bark must be used with caution ; and never where there is any appearance ofthe inflammatory diathesis till after proper evacuations. When, instead of these symptoms, the epidemic is accompanied with much debility and a tendency to assume the form of typhus, the bark must be given early, and in large quantity, and evacuations of every kind cautiously advised. Such are the principal circumstances to be attended to res* peering the exhibition of the bark in agues. It will be proper, before we leave this part ofthe subject, to say something ofthe different forms in which this medicine has been prescribed. It may be used ia extract, tincture, infusion, or decoction ; but it is now generally granted that the simple powder is the best preparation of it. It never succeeds so well as when given" in substance. REMITTING FEVERS. •12S Although we ought never to have recourse to the decoction, infusion, tincture, or extract, when the stomach wiil bc-ur the powder; yet when it will not, avc often find some of tl*ese prepa- rations useful. The infusion is prepared by ailoAving the bark- to remain in about six or ei:;ht times its weight of cold water for about 24 hours. Many prefer-this to the decoction, which is prepared by boiling the bark in water for a short time. The former of these, Dr. Lewis* observes, strikes a deeper colour with chalybeates than the latter. Bkeete prefers the decoction, but he thinks the infu- sion prepared with magnesia, in the manner pointed out in his Treatise on the Red and Pale Bark, preferable to either. The extract is prepared by boiling the bark with water for a short time, filtrating the mixture, and inspissating it by evapora- tion. Proof spirit extracts more of the virtues of the bark than water ; rectified spirit more than either. The gummy part is extracted by the water, the resinous by the spirit ; so that the best preparation of the bark, next to the simple powder, seems to be a combination of the tincture and the iniusion.f After the bark has undergone the action of these two menstrua, it remains perfectly insipid to the taste, and deprived of its odour. The re- sinous part of the bark seems to contain the astringency. When it is boiled with water, the turbid decoction is bitter and astrin- gent ; but when the matter rendering it turbid is deposited, ihe astringency is no longer perceiAred ; Avhile the bitter taste re- mains unimpaired. What has been called the resina corticis Pe- ruviani, and which hrchiefly if not altogether a pure resin, is ob- tained by precipitation from the tincture by water. This prepa- ration is more exceptionable than any of the others which have been mentioned* When the patient is a child, and we cannot persuade him to take the bark by the mouth, it may be injected per anum. It may be worth while also to try this method when the powder will not remain on the stomach. This however is a much less efti- oacious way of giving the bark. When it is given in clysters, some prefer the extract to the powder, suppot;i;.g it to contain much of the virtues of this medicine in small bulk ; there seems however to be no foundation for this preference. The external use of the bark has also been recommended, and has sometimes proved serviceable. It is not however to be de- pended on. This mode of giving the bark, like the last, is only to be had recourse to when it cannot be taken by the mouth, and it is only to children, who require a smaller dose, that wc can ex- pect it to prove beneficial. The mode of applying it is sewing * Se« his Materia Medica. X Skeete recommends adding a little of the tincture to the infusion, See his Treatise on the Red and Pale Bark. Vol. I. R lse INTERMITTING AND the powder into that part of the clothes, which is wrapt about the body. It is sometimes made into poultices, and applied to the stomach and wrists, or the decoction is used as a bath for chil- dren.* In some cases it is proper to give other medicines along with the bark. Wuen the strength is much reduced, the powder may be given in wine, and more or less of the wine taken as the state of the patient requires it between tho doses of the bark. When the stomach is very irritable, a dose of solid opium, or opium and camphire given with the bark, often enables the patient to retain it. There is nothing which is of more service in preventing the nausea and oppression which frequently attend the use of the bark, than a few drops of the vitriolic acid given along with it.f In soldiers, sailors, and others, who have been accustomed to the use of distilled spirits, brandy is often the most convenient vehicle in which we can give this medicine. Porter was recom- mended by Morton and Dr. Lind in the fever of Bengal. Lime water is particularly recommended by Skeete, as increasing the virtue* of the bark. It is generally proper to add a little gum arabic to any vehicle we employ, that the powder may be the more readily suspended in it. When the stomach is habitually weak, aromatics, bitters or as- tringents joined with the bark are often beneficial, they are re- commended by Mead, Brocklesby, and others.! When the bark occasions purging, we must have recourse to opiates and astringents ; the gum kino and extract of logwood is one of the best astringents in this case. If there is reason to suspect that the purging proceeds from acidity, which is fre- quently occasioned by the bark deranging the digestive powers, we must then combine with it some absorbent powder. If on the other hand the bark occasions costiveness, it is necessary to give along with it a gentle laxative ; for this purpose rhubarb is par- ticularly recommended by Dr. Mead ; it has the double advan- tage of moving the body and tending to restore tone to the sto- mach and bowels. In prescribing the bark, we often find it necessary to join to it * For the external use of the bark see the 2d vol. of London Medical Observations. | Dr. Lind properly recommends all kinds of acids, saline draughts and crystals of tartar, as proper additions to the bark when the thirst is urgent, and the stomach oppressed with bile X Dr. Lysons particularly re cm mends the snakeroot; he gave two- parts of the bark and one cf snakeroot. The dose of this mixture- was only a drachm, and the author asserts that two or three doses will rare- ly fail to say any distinct tertain or quartan. He also maintains that the disorder is less apt to return when cured in this way, than by the bark alone. See Dr. Lysons' Pi-actical Essays on Continual and Remitting Fe- ver, &c. REMITTING FEVERS. 131 something capable of concealing its taste. Milk is very generally known to possess this property. The various aromatic waters may be employed for the same purpose. " Among the materi- " als I have tried," Dr. Lewis observes, " for covering the taste *' of the bark, liquorice or its extract.was found .to answer the " purpose most efiectully, whether in a liquid form, or in that of «' an electuary." Liquorice and butter-milk have been particu- larly recommended for this purpose. Some prefer the bark in pills. This mode of giving it is very troublesome, as the pills must always be taken soon after they are prepared ; if they are allowed to become hard, which they are apt to do, from the quantity of gum necessary to make the powder cohere, they occasion nausea and oppression. When they become hard, they must be ground again to powder, and then by the addition of a little water they readily form a mass, which is as proper as at first for being made into pills. There are two kinds of bark at present in common use, the red and the pale. The genuine red bark is more bitter and as- tringent to the taste than the pale, and shews a greater degree of astringency when tried with chalybeate solutions. The red bark likewise contains more resin than the pale. But the propor- tion of the resin differs in •different parcels of it. Rubbing the pale bark with calcined magnesia, while we prepare the infusion of it, is said to increase the deepness of the colour, the astringen- cy, bitterness, and antiseptic power of the infusion. Calcined magnesia used in the same way with the red bark, produces none of these effects on it.* There can be little doubt of the genuine red bark having been found more powerful in the cure of agues than the pale, as appears from the observations of Saundersf and Rigbyi on this bark, and Skeete's treatise on the red and pale bark. Dr. John Hunter§ says, he often found the red bark more •effectual than the pale in removing; agues, but thought it was more apt to affect the bowels. But whatever be the efficacy of the genuine red bark, it is very doubtful whether that now sold in the shops be at all superior to the pale. Many are of opinion that it is not, and that it owes its deeper colour to being dyed. A quantity of the genuine red bark was first brought to England in a Spanish prize, captured in 1781, and it is very doubtful if any more of it ever came to this country. I have treated of the bark at considerable length, because in fact the cure of most intermittents is now almost entirely trusted to this medicine; and where it has met with a fair trial, it has * See Dr. Skeete's Treatise. f See Saunders on tlie Red Peruvian Bark. X See Rigby on the Red Peruvian Bark. $ See his- Account of tlie Diseases of the West-Indies. 132 INTERMITTING AND been attended with a degree of success in theee fevers which suf. fi<£t.r.tiy justifies the general partiality in its favour. Circum- stances may occur however to prevent our employing this medi-, cine; in some places it cannot be easily procured ; in others its Mj*h price often prevents the poorer ranks of people from using it in sufficient quantity. It is therefore necessary to be acquaint, ed with the articles which uwy with the greatest probabiUtyiof success be used in its stead. Besides, althoiqrii there are few of the articles I am about to point out upon the whole so successful in agues as the Peruvian bark, yet it has often happened that in cases where this bark has failed, some of these have succeeded. » I shall in the first place make some observations on the other barks which have been found capable of removing intermittent fever. The Angustura bark was first imported from the West Indies in 1788. It has been found successful though inferior to the Pe- ruvian bark in the cure of agues. We are not acquainted with the tree whic.h produces it, its place of growth, Sec. Respecting these points Mr. Brand, in a treatise on it, the second edition of which appeared in L793,-makes some conjectures. The Angus*' tura ia given in smaller doses than the Peruvian bark ; about 15 or 20 grains are a moderate dose. It is less apt to disorder the bowels than the Peruvian bark, and has succeeded in agues where both the red and pale bark had failed. It is to be observed that an intermittent's yielding noAV and then to a second remedy, after the first has failed, is no proof of the second being upon the whole preferable. There are many instances of simple bitters having succeeded in the cure of agues, after the bark had failed. The change, although to a medicine upon the whole less efficacious* - seems often beneficial. The reader will find an account of the Angustura bark in the treatise just mentioned, and in several pa* pers referred to in that treatise. The cinchona Jamaiccnsis, discovered by Dr. William Wright;., has also been used with success in intermittents; it seems infe- rior however to the bark la-t mentioned. Dr. Wright's account ofthe cinchona Jumaicensis is in the Philosophical Transactions' .' for the year 1772. There are also some observations on k in Skeete's Treatise on the quilled and red Peruvian bark. The St. Lucia bark or cinchona Caribbcea has also been found successful in these fevers. Dr. Kentish has published some ex- periments made with it, and Mr. Wilson, expected, the patient should avoid exposure to cold, should be put to bed and kept warm. Some have recom- mended the use of the warm bath. He should avoid taking much food or drink ; and if there is no tendency to the inflamma- tory diathesis, what he takes should be stimulating. Diaphoret- ics are frequently serviceable, given a little before the fit is ex- pected ; for if we succeed in keeping up a sweat, the accession of the paroxysm is often prevented. " lntermittentes tertianas u autuinnales," Sydenham observes, « hoc pacto aggredior iEgro " in leer.do composito et stragulis undique cooperto sudores pro- " voco, serolactiscerevisiato, cui salvia; folia incocta fuere, oua- " tuor circiter horis ante paroxysmi adventum." In cases where metallic salts, that is, metals combined with acids have lieen taken, con osive sublimate or sugar of lead for example; drinkiiw immediately a large quantity if a weak alkaline solution is the best means ot preventing bad consequences. -In this case the metallic salt is decom- posed by the alkali as soon as it is received into the stomach the alkah combining with the acid, and leaving the metal in a less active or wholly inert state. It has been proposed, instead of using the oxvd of ;. rsuiic in mtei-mittviits, to employ an arsenical salt, which would lie more easily dis- solved in water, and such a salt has been prepared bv Mr Milner Pn- tessor of Ch\ mistry at Cambridge, and has been used' it is said with suc- cess in intermittents. The bad effects of an over dose of this as of other- metallic .vilis would probably be obviated by the above alkali-ie solution 1 his sol'ruu: us prepared by dissolving an ounce of vegetable alkali in a ga lop (f water, ol which the patient is to drink as much as he is able. It i, said, that the acid of arsenic is as innocent as the metal itsi.lt" so that ltisonly vyuen combined with a small proportion of cxvqcu or with an acid that it is poisonous. A Treatise was published abroad a few years ago, containing observations on t'^e effects of arsenic combined-with dif- ferent proportions ot oxygen. Hie fact just mentioned (I have been in- formed) is ascertained by these observations, winch I have not been able to meet with. Vol. I. S 138 INTERMITTING AND It is the general opinion, that the stomach and bowels If loaded should be cleared at this period, by the operation of an emetic and cathartic. Few medicines more poAverfully promote^perspi- ration than emetics, and to this their effects in preventing the paroxysm of r^ues must in part be ascribed. Emetics however seem here to operate also in another way. Any thing capabfe of making a strong impression on the nervous system, is occasion- ally found to prevent the recurrence of the paroxysm. There are few things which more powerfully affect every part ofthe system than the operation of an emetic. The employment of' cathartics at this period is a more doubt- ful practice, and seems to have been rather the result of hypothe- sis than observation. Should the acrid contents of the bowels produce spontaneous diarrhoea, it may be proper to encourage it by warm diluting liquors. Checking the purging would lay up a fruitful source of irritation to aggravate the symptoms of the ensuing paroxysm ; but if purging do not spontaneously occur, it ought not to be induced at this period, that is, a little before the paroxysm is expected. The means which prove successful in preventing the paroxism of agues in the way 1 am speaking of, produce one of three ef- fects : They make a sudden and strong impression on the ner- vous system, or they quicken the circulation, or they induce sweat. Some medicines are capable of producing more than one of these effects, and some all three ; any one of them hoAvever is often capable of preventing the paroxysm of an ague. Purging produces none of these effects, but rather their oppo- sites. It makes no powerful impression on the nervous system ; it retards the circulation, by enfeebling the powers which support it ; and so far from promoting sweat, it even checks it when, it has been induced by other means. From every thing Ave know of .the nature of agues, purging seems to be one of the most powerful means that could be thought of for inducing the par- oxysm. Sydenham indeed recer.imended purging along with sweating at this period ; but insists particularly on this, that the sweating be not checked by the stools ; and adds, that the cathar- tic ought to be omitted when the patient is reduced by the contin- uance of the disease or any other cause. The reasons which Sydenham gives for employing cathartic* in any case at this period, are such as sufficiently p6int out the hypothetical foundation on which the practice rests. When the tAVo opposite motions of sweating ancl purging, he observes, are excited at the same lime, they confound and disturb the ordinary course of the paroxysm. Notwithstanding his opinion, we can perceive from what Sydenham says, that his extensive experi- ence sufficiently pointed out the error of this practice. He often found it necessary, he informs us, to give a dose of opium after tlie operationaf the cathartic ; and before the accession of the REMITTING FEVERS. J39 paroxysm ; thus doing what he could to remove for the time the debilitating effects of the cathartic* and dispose to sweat. For similar reasons he properly recommends opium after the operation of the emetic, if this be over before the fit commences. Opium not only makes a strong impression on the nen'ous sys- tem, but also gives a temporary vigour to the powers supporting circulation ; and is upon the whole the most powerful diaphoretic of which we are possessed ; so that there are few medicines bet- ter calculated to prevent the accession ofthe paroxysm. It may be used with advantage at this period, perhaps, (as we have seen it in the hot fit) combined with nauseating doses of emetics. It is doubtful, however, whether the debilitating effects of nausea are proper when the fit is expected- In whatever manner we use opium with a view to prevent the fit, the patient under its operation should be put to bed, kept warm, and supplied with tepid diluting liquors. When Ave have endeavoured in vain during the first paroxysms of the complaint to prevent their accession, by inducing vomiting or SAveat, we are not to persevere in the use of these means ; since if they do not soon remove the disease by their debilitating effects, they render it more obstinate. Dr. Cullen remarks, that endeavour- ing to prevent the paroxysm by keeping out a SAveat, has often changed the fever to the continued form, which he justly observes is always dangerous. Many medicines.however have been employed with the same view, which instead of weakening tend to restore the tone of the system. The chief of these is a medicine which I have already had occasion to speak of at considerable length. It has been found that a large quantity of the bark received into the stomach immediately before the paroxysm is expected, frequently pre- vents its return. Dr. Millar and others have observed, that an ounce of the bark taken at a single dose when the fit is expected not only often prevents the paroxysm, but sometimes wholly re- moves the complaint. This hoAvcver is far from being the best mode of giving the bark. Few stomachs can bear so large a dose of it, and it seems to ansAver better when given at intervals for some time before the accession of the paroxysm. In this way not only a greater quantity m^iy be accumulated in tho stomach and intestines at the time of accession ; but by giving it at inter- vals its effects appear to be accumulated in the system, for those of each dose continue for a considerable time after it is taken ; some suppose, and not without reason, while any part of the medicine remains in the alimentary canal. A vast variety of articles have been employed at this period, chiefly by the vulgar, and have occasionally succeeded in prevent- ing ague fits. These arc, either such as make a strong impres- sion on the stomach, as spirit of turpentine, wine, warm strong beer, brandy, Sec. with a variety of peppers and other acrid sub,- 140 INTERMIT! ING AND stances ; or such as strongly impress the mind, sAvallowing a liv- ing spider, a powder prepared from human liones, and a thou- sand other things of this kind. By regular practitioners the powder of cammomile flowers, wormwood, or other strong bitters, have been used hi the same way. The foetid gums have also occasionally been found service- able ; and some recommend a variety of* external irritating ap- plications, salt mixed with the white of eggs applied to the wrists, &c. SUCH are the means of cure to be employed at the various periods cf intermitting fc.cr, between the accession of one paroxysm and that of the next; between which and the third pa- roxysm the same mode of practice, varied as the symptoms vary, is to be repeated; and so on through every interval till the fever is removed. If the bark be immediately discontinued on the removal, of agues, they are apt to return ; especially if they have lasted for a considerable time, and the patient has been much reduced. It is therefore proper in general to continue the bark for some time longer, gradually diminishing the dose, and giving it at the peri- ods at which the fever, had it lasted, would have recurred. It is also proper for those who have lately laboured under agues, not only to avoid exposure to marsh miasma, but all those circumstances above enumerated as favourable to the operation of marsh miasma in producing agues. Exposure to cold, irregu- larities in diet, or any other cause which debilitates, is capable of renewing these fevers. When exposure to such causes is una- voidable, as in the rainy seasons of sultry climates, the bark ought to be used as a preventive.* In all cases the rules respecting diet and exercise in the apyrexia must be attended to for some lime after the removal of agues, both in order to prevent their re- turn, and to restore the patient's strength. Of the Modus Operandi of the Medicines employed during the Apyrexia of Intermittents. ON this part of the subject I have only to remind the reader of a fcAv observations v. hich have already been made. I have just had occasion to point out the viay in which the me- dicines given at the time the fit is expected, seem to act in pre- venting its accession. The effects of many of these can only be ascribed to the impression made on the nervous system, since they are are too sudden to be attributed to any change induced on the fluids. It is only in this way that we can account for the * See the 47th and following pages cf Dr. Lir.d's Efsr.y on the Means cf preserving the Health of Seamen. REMITTING FEVERS. 141 effects of the bark, when the paroxysm is prevented by this med- icine given only half an hour before the time at which it should have appeared. And when Ave reflect on the observation of Dr. Jackson, Dr. Monro and others, that if we persevere in giving the bark, the fever will be removed, although the medicine is constantly discharged by vomiting and stool, we have every rea- son to believe, that in whatever way the bark is exhibited, its , effects in the cure of agues are to be attributed to its action on the nerves of the stomach and intestines. The hypothesis of the bark removing agues by its antiseptic power, were it not maintained by some late respectable authors, and very generally blended with medical writings, would not de- serve to be mentioned. Is there any species of ague, in which the fluids have been proved to be in a state of putrescency ? Are there not many, in which such a state of the fluids has not even been suspected ? Or, if it did exist, have we not every reason to regard it as the consequence, and not the cause, of the fever? But admitting both these points, admitting, in the face of the most direct evidence, that in agues the fluids are in a state of pu- trescency, and that this state of the fluids is the cause of the fever; will it be seriously asserted, that a quantity of bark is ever re- ceived into the mass of circulating fluids, sufficient by its antisep- tic power to correct their putrescency ? BOOK II* OF CONTINUED FEVER. V^ ONTINUED Fever is defined in the Introduction, an Idic* pathic Fever with slight remissions and exacerbations. For the sake of perspicuity, this fever was divided into two species, the Synocha, and Typhus. The Synocha was defined, that species of fever in which tlje temperature of the body is greatly raised, the pulse frequent, strong, and hard, the urine high coloured, and the sensorial func- tions but little disturbed. Typhus, it was observed, is characterised by being a contagious disease, by the temperature being little raised, the pulse small, weak, and generally frequent, the urine little changed, the sen- sorial functions much disturbed, and the strength greatly reduced. It was observed, however, that although this division is useful in practice, and still more in acquiring a knowledge of continued fever, yet it cannot be regarded as accurate, since we scarcely ever meet with simple Synocha or Typhus ; almost every con- tinued fever assuming the form of the Synochus, that is, being a combination of the Synocha and Typhus, beginning with the symptoms of the former, and terminating in those of the latter. In the proportional degree in which either set of symptoms pre- vails, there is infinite variety ; and it is convenient to apply the terms Synocha., or Typhus, according as the symptoms of the one or the other predominate. CHAP. I. Of the Symptoms of Continued Fever. JL HE symptoms of continued fever are less regular and more protracted than those of agues. The cold stage is more fre- quently absent in continued, than intermitting fever, ancl general- ly consists of irregular chills, frequently interrupted and reneAved, or of short fits oi cold and heat, which succeed each other alter- nately for the first day or two, and often continue to do so, after the temperature of the body, measured by the thermometer or the feeling of another person, is uniformly raised. The cold and shaking are never so severe as in agues, but the attending symptoms, langour, weariness, soreness of the flesh CONTINUED FEVERS. I4S and bones, head-ach, &c. are upon the whole more so. The pulse during the chills in typhus, as in the cold stage of agues, is smali and frequent ;* but in synocha, even during the chills, it is often strong, regular, and full. These symptoms are at length succeeded by more permanent heat, often partial at first, soon becoming general. But the change from the cold to the hot stage is both more gradual and less stri* king, than in intermitting fever. The strength and fullness of the pulse increase as the chills abate; but this change is seldom so considerable as at the same period in agues; for the pulse from the first is generally pretty full and strong,if the fever be synocha; and if it be Avell-marked typhus, it seldom acquires a great degree of strength, even after the heat is generally diffused. In this respect, however, there is much variety. It has already been observed, that all fevers, at their commencement, assume more or less ofthe form of synocha; and it generally happens, in con*- tagious fevers, that although the debility is considerable while the chills continue, yet after these, the pulse acquires a considerable degree of strength, which it often retains during the first days of the complaint. As the hot stage advances, the various functions are affected in the same way as in agues'; but the heat, except in well-marked synocha, is generally less in continued, than in intermitting, fever. It is not, as in the latter, relieved in few hours by sweat, but con- tinues along with the other symptoms of the hot stage, suffering more or less evident remissions, once or twice in the day, often for weeks, or even months; and at length frequently leaves tho .patient gradually, without■ a remarkable increase of any of the excretions.f In other cases, the symptoms of continued fever * The pulse is generally less frequent at the commencement of conti- nued, than that of intermitting fever. " The pulse during the first 24 hours beats seldom less than ninety " times in a minute, and very seldom more than one hundred and five in " a minute; whereas in an ephemera, or in the first paroxysm of an in- " tcrmittent, it very often rises to one hundred and twenty or thirty pul- " sations." See Dr. Fordyce's third Dissertation on Fever. Part I. f During the exacerbations the heat generally rises cne or tAvo degrees above the mean heat of the fever in the trunk, and more in the extremi- ties. See Dr. Currie's Med. Reports on the effects of water, cold and warm, &c. In the cold stage of continued fever,"Dr.Currie observed tlie heat under the tongue as low as 92° of Farenheit, and he mentions 105° as the highest degree of febrile heat generally observed ; but he takes notice of one case of continued fever, in which it was as high as 108°. While the cold stage is changing to the hot, he remarks, some parts of the body are above, while at the same time others are below, the healthy de-1 gree ; nor is the heat diffused with any regularity, but is sometimes great- er in one place, sometimes in another, and this irregularity continues till by degrees the heat becomes general and steady. Dr. Currie seems to be Wrong however in supposing that the irregularity in the real temperature is die sole cause of the irregular sensations of heat and cold of which thfe patient at this period complains, which often continue after the htat. 144 CONTINUED FEVERS. are more suddenly relieved in various ways, afteitrards to be pointed out. During the first days of the complaint tlie symptoms general- ly return with increased violence after the slight remissions which take place ; if they do so for many days the danger is great. "When they return Avith less violence after each remission, the fe- ver is said to have taken a turn, and the prognosis is favourable. It frequently happens, however, that the symptoms continue to return Avith nearly the same degree of violence for many day a, or even for weeks ; and then, if they are not alarming, ancl the patient bears them without a remarkable diminution of strength, although the disease will prove lingering, the event will probably be favourable. Such are the general course of continued fever, and the prin- cipal circumstances in which it differs from agues. It is necessas ry to consider its symptoms at greater length ; and it will be thfi most distinct plan, to give separately those of the two species, Into which it has been divided, namely, the Synocha, that species. in which the excitement is above, and the Typhus, in which it is below the healthy degree. SECT. I. Of the Symptoms of Synocha. THE symptoms of synocha are as simple, as those of typhus are complicated. The prostration of strength, which precedes the attack of fevers, is generally less considerable ; and the cold stage is more frequently absent in synocha, than in typhus.' The pulse, even in the cold stage of synocha, is seldom small or very frequent; after the heat commences, it becomes full, rap- id, equal, or as it has been termed, vibrating; still however its lrequency is less than in those fevers in which debility prevails. The respiration is frequent, hurried, generally oppressed, and attended with a dry cough. The heat is greater than in other continued fevers, and of that kind which has been termed burning, in contradistinction to acrid.* f he face is-full and florid, the eyes inflamed and inca- pable ol bearing the light. The secreting powers are more completely suspended than in most cases of typhus. The skin, mouth, and throat are dry, k and the mucus covering the tongue becomes foul ancl viscid The urine is scanty and high coloured, and the. bowels costive. measured by the thermometer, remains in the extremities as well as in Hie trunk uniformly above the healthy degree. CA"™umts ai * e11 « m * Seethe observations on the heat in t> phus, in sect ii. of this chapter. CONTINUED FEVERS. US riiC.head-.ich is .generally considerable, accompanied with throbbing of the temples or tinnitus aurium. The depravation*Qf the senses however is less frequent in synocha than in typhus, nor is delirium a common symptom of this fever; but when it does occur in synocha, it rises to a degree which from the debilitated stale of the system Ave hardly ever meet with in typhus. The patient becomes frantic, and is with difficulty retained in bed. When the delirium is obstinate in synocha, we have reason to suspect an inflammatory affection of the brain; which there is still more reason to dread, if the patient is oppressed with coma. In enumerating the symptoms of phrenitis, I shall have occa- sion to point out the circumstances which form the very imper* feet diagnosis Ave are possessed of between this complaint and synocha. When synocha proves fatal within a few days of its com- mencement, (Avhich, if it ever happen, is a rare occurrence) the) pulse', it is said, does not become weak or intermitting before death ; the patient seems to be carried off by the violence of the excitement. When the disease continues for a longer time however, and the remissions are at all evident, the pulse during these (although the fever has not yet assumed the form of typhus) becomes weak and languid, the patient appearing to be exhausted by the fore- going paroxysm ; which is reneAved however in a short time, with all its former violence, or even stronger marks of excite- ment. The hemorrhagies, which frequently occur in this fever, are generally from the nose, ears, lungs, rectum (if the patient hap-? pen to labour under the hemorrhoids) or from the uterus ; and irrc almost always favourable ; the blood discharged has the healthy appearance, except that the coagulum is frequently cov- ered with the buffy coaL* Hemorrhagies from the higher parts of the intestines, kidneys, urethra, skin, eyes, 8cc. are rarely, tha tAvolast perhaps never, observed in synocha. Such are the symptoms of well marked synocha. They vary in different cases from those just enumerated, to the mild febrile symptoms attending a common catarrh. After the symptoms of synocha have continued for some time, if they do not terminate the patient's life, they always, at least in this country, begin to be changed to those of typhus ; so that the whole disease is a synochus. The proportional duration, as> well as violence, of the synocha and typhus in this, which has been termed the mixed fever; is different in different cases ; and proves an endless source of variety. The manner in which the * I shall afterwards have occasion to explain the nature of this ap- pearance. Vol. I. T 146 CONTINUED FEVERS. symptoms of synocha are changed into those of debility, also va- ries much. The duration of fevers in general is shorter, their symptoms more violent, and their changes more rapid, in tho warm, than in the cold, and temperate climates. The symptoms which foHoAV the state of increased excitement, are the most dan- gerous, as well as most varied part of the fever. These I am now to lay before the reader; where they predominate, the conv plaint is termed typhus* SLLCT. IT. Of the Symptoms of Typhus. AN uneasy and peculiar sensation in the stomach, sometimes' attended with nausea and giddiness, frequently denotes the ap- proach of those fevers, in which the symptoms of debility pre* vail.* In many cases, however, this sensation is scarcely, or not at all perceived ; and the fever comes on with lassitude, anxiety about the pracordia, alternate heats and chills, or a sense of creep* ing in different parts of the body, which has been termed hor- ripilatio. The patient eomplains of uneasiness of the head, and fixes his attention with more difficulty than usual; is dejected and wishes to be alone. His appetite is impaired, he becomes restless, or if he remains long in the same posture, it is rather a sensation of languor, than of ease, which prevents him from changing it. He is disinclined to every exertion both of body and mind. Either sleep forsakes him, or he is more inclined to sleep than usual, and then his sleep is such as does not refresh, disturbed of groans and starts. At this period the pulse for the most part is frequent, smalli and easily compressed ; in other cases it is nearly natural, ancl the patient often labours for some days under more or fewer of these symptoms, not well enough to engage in business, nor suffi- ciently indisposed to be confined to bed. The first symptoms of typhus are often more severe. The patient is attacked with a troublesome head-ach, acute pains in the back, loins, and extremities, which often resemble a general rheumatic affection, a distressing sense of weariness, much thirst, and nausea ; sometimes attended with a burning pain of the sto- mach ; more frequently by vomiting, vertigo, dimness of sight, or numbness of the extremities. In some instances, this fever attacks with still more violence. The rigors from the first are strong, the pulse soft, small, fre- * This peculiar sensation is taken notice of by a variety of authors, Dr. Jackson in his Account of the Fevers of Jamaica, Dr. Smith in his'Ac- count cf the Jail Fever of Winchester, &c CONTINUED FEVERS. 147 quent, and sometimes irregular. The general uneasiness, con- fusion of headf and dejection of spirits excessive. At the very commencement the debility is often extreme, the tongue trembles impeding the speech, tlie limbs shake, and the patient Avith diffi- culty supports himself. There are even instances of people, on the first attack of typhus, falling suddenly to the ground, as if thunderstruck.* There are feAv complaints in which the symptoms are more varied, than in typhus, whether we regard its accession or its progress. Of tlie State ofthe Animal Functions in the Progress of Typhus. As the complaint advances, the debility of the muscles of vo- luntary motion increases. In the advanced stage, the patient, incapable of any exertion, lies on the back, and if turned on either side, soon resumes this posture, he even slides insensibly towards the foot of the bed, and has not power, although he understands what is said to him, to put out his .tongue, which is affected with a tremulous motion. In other cases, but rarely in the fevers of this country, the pa- tient, tormented with extreme anxiety, is constantly changing his posture, and in some fevers, particularly in the plague, this symp- tom is often so violent, that it occasions a perpetual Avrithing of the body, so that the patient seems to be in agony, but is generally quite incapable of giving any account of his feelings.f When he is less restless, the limbs, as death approaches, are sometimes affected with numbness or palsy, more frequently they are moved by a constant twitching of the muscles, often the forerunner of general convulsions, in which he expires; sometimes in the first attack, more generally after several returns of them. In some cases, the muscles ofthe limbs are affected Avith more permanent spasms, and cases are on record, in which complete tetanus has (.upervened towards the fatal termination cf malignant fevers4 The head-ach is sometimes confined to the under part of the orbits, sometimes to the orbit of one eye, attended with strong throbbing of the temples ; the carotid and temporal arteries often beating strongly, while the pulse at the wrist is small and weak.|| * 1'his sometimes happened in the late dreadful fever of Grenada, de- scribed by Dr. Chisholm. X This symptom, which is a very fatal one, has been termed a mortal inquietude. X See Vogcl, De Cog. et Cur. Mora. || When this symptom is obstinate, and accompanied with an acute or deep seated pain of the head, or with a considerable degree of coma or delirium, it generally denotes an inflammatorv affection r.i the brain or its membranes. In these cases, abscesses are often found in the encephalon after death. Cases of this kind are related by Sir John Pringle and others. lk\ Foitiyce has justly observed however, that abscesses of tile brain very 146 CONTINUED FEVERS. ' The uneasiness and confusion of head increase with the debili* ty, and often en the second or third night a degree of delirium comes on, which goes off, however, on the succeeding day, and continues to return in the evening for several days. As the symp- toms increase, a wandering of the mind remains throughout the day, and often increases at night to a degree of phrenzy, resembling the delirium of synocha. More frequently, however, the exacerba- tion ofthe delirium at night is less remarkable, and the patie^is rather stupid than violent. At a more advanced period he con- tinues uniformly sullen and sad, muttering to himself as if brood- ing over some heavy misfortune. The countenance is dejected, and the eyes heavy and inflamed. When the evening exacerba- tions are remarkable, the countenance appears more lively, the dull appearance of the eyes especially is less observable, and the patient is then easily irritated, speaks quick and answers hastily.* rarely occur in the fevers of this country. The same throbbing, also fie quently indicating an inflammatory affection, is sometimes observed in' other parts ofthe body, particularly in the fe\ ers of warm climates. u In " the yelloAV fever," Dr. Linning observes, ** there is a remarkable throb- " bing in the temporal arteries and hypochondria; in the latter sometimes' " so great as to cause a constant tremulous motion of the abdomen." * The ideas, presented to us by the memory and imagination succeed each other with such rapidity, that unless we employ some means for the purpose of detaining them, we are unable to compare them together, and consequently to draw any inference from them. The means com- monly employed to detain our ideas for a sufficient length of time are, words. VV e have associated every idea with some particular sound, and bjf recollecting the associated sound we can detain the idea for any length c£, time. When we wish to compare two ideas in order to draAv an infer-, ence from them, by recollecting the sounds with which they are associa- ted we detain them till the comparison is made. Let any one endeavour,; to pursue a train of reasoning without recollecting the words associated, with the ideas passing through the mind and he will find it impossibly. Li those cases, Avhere the number of ideas to be compared is great, and the reasoning consequently complicated, we haA'e found it necessaiy U>i invent means still more effectual of detaining our ideas, by applying; ta some of die external organs of sense an object which sliall constantly i excite the ideas which we wish to detain. Thus in mathematical de?,, monstrations the ideas cf curves, lines, angles, and of their relative posi- tions, are detained in the mind by keeping the eye fixed on a diagram, or if the person bv blind, the same purpose is answered by means of the. sense of touch and a diagram made of wood. And it seems to form tlie chief difference betAvcen the intellectual powers of a man and brute ani- mals, that the latter are neither possessed of language nor any other' means of detaining their ideas ; in consequence of which they are incapa- ble of con.paring them, and consequent!/ of reasonii.j^, to any extent. This is gi-ierally the state of our own minds in dreaming ; we do not then enipioy v.crds to arrest our ideas, and they pass thiough the mind with a rapidity which prevents us from comparing them. The rapidity widi which ideas often pass through the mind in sleep appears at first view incredible. Dr. Crcgo.y used in his Physiological Lectures to relate the case of a lady, who was subject to dreams while engaged in the common occupations of life ; their tiuratic.;i was so Lho.-t, thattiiey often passed unobserved by those v. ho conversed with her, yet it required many hours to give an account of the crowd cf ideas which in so short a time had passed through her mind. " The rapidity cf the tuccc-sion oftrara- CONTINUED FEVERS. 149 In other cases a considerable degree of coma comes on ;* if this state increases* the jaAV at length fidls, and complete apoplexy supervenes. ■ > The different organs of sense are variously affected in the progress of typhus. Deafness is generally, not always, a favour- able symptom.t A depravation of the sight, on the other hand, '"actions in our dreams," Dr. Darwin observes, Zoonomia, vol. 5, p. 205, " is almost inconceivable ; insomuch that when we are accidentally " awakened by the jarring of a door, which is opened into our bedcham- " her, we sometimes dream a Avhole history of thieves or file in the very "instant of, waking." Qur, seldom using the ordinary means to detain ».ur ideas in sleep may account for many of the phenomena peculiar to dreaming.' The most incongruous appearances do not seem to us at all wonderful ;■ because it is only in consequence of comparing the present idea* With, former ideas that it can seem so. Were we deprived of all those ideas with which experience has furnished our minds, nothing would seem wonderful. A miracle only surprises because it contradicts the common course of nature ; but were we ignorant of the common course of nature, we could not perceive the contradiction.' It is the same thing, Avhether we have no fund of ideas laid up in the mind or are pre- vented from making use of them. To the same cause we may attribute many of the phenomena of de- lirium. But there seems to be the folloAving difference betAveen dream- ing and delirium : If in dreaming any cause occur to detain our ideas, we compare them and reason from them with as much accuracy as when awake. Thus 1 have frequently observed, that when I dreamt lAvas en- gaged in conversation, in which case of course I employed words, tfie tram of thought was as consistent with experience as in my waking hours. I mentioned this circumstance to a gentleman, av ho told me, he also nad ob- served that when he dreamt that he was speaking, lus ideas Avere never inconsistent. In delirium, on the contrary, although the ideas are detained in tlie mind for a sufficient tength of time, Ave are incapable of comparing them together so as to draw the proper inference.' Delirium also differs from dreaming in the ideas themselves being generally confused ar.d in- distinct. The foregoing observations respecting language strictly apply only to the first use of it, for by habit words come to be used without suggesting the ideas with which they were at first associated, in the same maimer that figures are used in arithmetic without any reference in the mind to the numbers which they represent. The relations Avhich the Avoids bear to each other at length supersede those which they-originally bore to the ideas Avith Avhich they were associated. We certainly say that two and two make four, Avithout the ideas originally associated v. ith two and four being suggested to the mind. It is evident that in whate\ er way Ave use words, either for the purpose of suggesting and retaining the original ideas, or of suggesting and retaining the relations Avhich the words bear to each other, tlie foregoing observations respecting dreaming a.e equally applicable. * Ti this state the patient often recehres into his mouth any thing pre- sented tg him, but seems as if he had forgot lo swallow it, so that it re- mains in tile mouth or runs out on the lied clothes. " If the medicine or drink be presented a second time while the Trst *' quantity still remains in the mcutii, the patient often s.valloAvs this to re- •• ccive Avhat is offered, when no other means can induce him to do so." See Moore's Medical Sketches. f Dr. Rush and others mention fevers in which deafness was found to be u very unkuoiuabie symptom. Ut CONTINUED FEVERS. is among the worst symptoms of the complaint. The patient, a* the fatal termination approaches, frequently starts up, catching at things which he sees passing before him, or picks the bed clothes, which appear to him striped or covered with black spots; sometimes every thing appears indistinct as if seen through a mist. The eyes indeed are variously affected throughout the dia- ease ; and some assert, that from their appearance alone they can determine the state of the patient. In the commencement of typhus they are dull and languid ; the tunica albuginta having a bluer, and sometimes whiter, appearance than ordinary. In the furious delirium they are red, quick, and piercing ; in the comatose, they are generally inflamed also, but heavy, half shut, and as if glazed. The last of these appearances indicates much danger ; but the prognosis is still worse, if* blood be cxtravasated in them. For some time before death they appear hollow, invob untary tears sometimes flow from them, and they become fixed and glossy. The sensibility of the skin seems often much im- paired ; and the taste and smell are sometimes almost wholly lost. The former is often otherwise vitiated, the patient complaining of a nauseous bitter taste, which mixes itself with every thing he takes. Of the State of the Vital Functions in the Progress of Typhus. THE pulse continues soft, weak, small, generally very fre- quent,* and if the symptoms increase, often becomes intermitting * In tedious nervous fevers, in which the symptoms are moderate, the pulse is often as slow as natural, for some hours during the day; and in the more malignant forms of typhus, it has sometimes been observed a great deal slower. I mean even in those of this country. In the fevers of *ome tropical climates, this is much more frequently tlie case. This state of the pulse in malignant feAers is taken notice of by a variety of authors, particularly by those who give an account of the fevers of the West Indies, Dr. Fordyce in one of his Dissertations on Fever observes, that the puis? is sometimes as low as 50 or even 45. In the late dreadful fever of "Phila- delphia, Dr. Rush found the pulse at 44, and in one instance as low as 30.'' 1 he pulse at a certain period of the yellow fever becomes as slow or slower than natural, and continues so till within a short time cf the pa- tient s deatn; for recovery is rare after this change of the pulse take! place. When the pulse becomes slow, the heat at the same time sinks U» die natural standard, and sometimes below it. This and the other pecu- liarities of the fevers of sultry latitudes depend on some local affection. The slow pulse indicates an affection of the brain, which is failher indi- cated m many cases of the yellow fever by a dilatation of the pupil and squinting. Dr. Cmsholm particularly takes notice of the slow pulse and dilatation of the pupil m the fever of Grenada, and found water in the ventricles ot the brain m those whom he examined after death The yellow fever is so called from the skin being tinged with vellow- when the yellowness is late in appearing, it sometimes comes on'so sud- denly that the patient almost instantly becomes cf a vellow deep oranee or copper colour. This circumstance, together with the mine ancl dV charge from blistered parts not always appearing yellow when the skin * so, demonstrate, contrary to what was once supposed, that the yellow CONTINUED FEVERS. 15-1 dr otherwise irregular. As death approaches, its weakness ancl irregularity become more remarkable, till at length the extremi- ties grow cold and the pulse cannot be felt. This sometimes hap- pens ten or twelve hours before death. There is a tendency to syncope on the slightest exertion, pai licularly in the erect pos- ture ; and for some time before death the debilitated state of tha circulation occasions a shrinking of the features, and conspires with the relaxation of the muscles of voluntary motion to givei that peculiar expression of countenance termed Fades Hippo* erotica, a presage that cannot be misinterpreted by the most inex- perienced. The countenance assumes a livid, cadaverous appear- ance, the nose is sharpened, and the cheeks become hollow. The face however, during the progress of typhus, is sometimes flushed, and more frequently bloated. The state of the breathing corresponds to that of the circula- tion ; it is weak, generally frequent and interrupted with sighing or a dry cough ; but as the debility increases, it often becomes calm and less frequent than natural, sometimes rattling. , The voice is low, weak, often shriller or hoarser than natural* and sometimes Avhcezing. Its being much affected in any of these ways affords an unfavourable prognosis. It is always a favourable sign when it again becomes natural. The heat of the body at the commencement of typhus is sel- dom much increased, and has been observed even in the progress of the complaint to be little more than natural-* But in general, after the first days, especially when the worst symptoms shew themselves, a person touching a patient in typhus perceives a heat of a penetrating kind, which remains in the hand for some time after it is removed from the patient, f Colour in this fever is not owing to the presence of bile in the circulating fluids. It sometimes happens towards the fatal termination of malignant fevers^ that the pulse at the wrist, before it is wholly lost, beats for some time with less frequency than the heart. * This is often the case in Avhat has been termed the nervous fever, th« Typhus Mitior. " Calor non raro naturalem vix superans," Frank ob- serves, in describing this fever. It is not uncommon in malignant fevers, particularly those ot warm climates, for the extremities to be considerably below the natural temperature, while there is a burning heat in tile breast and other parts of tlie trunk. f This peculiarity of the heat in typhus has been remarked by a variety of authors. " In the beginning," Sir John Pringle observes, " the heat is " moderate, ancl even in the advanced state, on first touching the patient, " seems inconsiderable; but upon feeling the pulse for some time, I have ** been sensible of an uncommon ardour, leaving an unpleasant sensation " in my fingers for a few minutes after. The first time I observed this," lie continues, " I referred it to the force of imagmation; but I was assured " of the reality by repeated experiments, and by the testimony of others, * who, without knowing my observations, had made the same remark." " On pressing the skin of die patient," says Dr. Moore, " a sensation of 152 CONTINUED FEVERS. Of the State of the Natural Functions in the Progress of Typhus. THE tongue at the beginning of the fever is covered with a thin white mucus; as the disease advances, this mucus becomeH thicker and of a brownish colour, and the ckumyness ofthe mouth and brown colour of the tongue generally increase with the fever. In the advanced stage deep cht>ps often form in the tongue, the mucus covering it becomes fetid, dry, and firm, anil a corresponding change taking place in that v/hich besmears the teeth and other parts cf the mouth, and probably also in the mu- cus of the trachea and bronchia, the breath*becomes oflensi\^, and the deficiency of moisture renders tl\e speech inarticulate. ■ Sometimes however the tongue continues moist to the end#f the disease ancl then, particularly in the middle, it often assumes a yellowish or greenish appearance. In other cases it is dry and smooth, of a shining dark red, which at last becomes brown or almost black, while at the same time a black furring covers the lips ancl teeth. The last appearance of the tongue sometimes su- pervenes in the progress of fever, although at an earlier period it has been covered with mucus. There is often a difficulty of swallowing from the dryness, sometimes from a paralytic affection, now and then from convul- sive* contractions of the throat; the fauces are often covered, particularly towards theend of the disease, with aphtha;, that is, specks of a white, brown, or blackish colour, often becoming ulcerous : ancl when they occur in the worst kinds of fever, very commonly the forerunner of mortification.! We shall have occa- sion to consider this eruption more particularly when 1 come to speak of it as characterising a species of synochus. " a peculiar penetrating heat remains on the hand for some minutes after* " whereas the heat communicated by the skin of a patient in the iiiilaav " matory fever, is more transient." Dr. Huxham, in his work on the ulcerous Sore-Throat, has also taken notice of this peculiarity of the heat in typhus. '' There is a peculiar biting " heat," he observes, " in persons labouring under malignant fevers. (Ju " ™rst,t0UCnmS me s!iin the heat seems very little if at all above natural; 44 but by continuing the finger a longer time on it, you are sensible of a " disagreeable scalding in it, which sensation remains in the finger fort " shoi't time after you have quite removed it from the sick person. This, " he adds, Quesney calls la chaleur d'acrimnnic, and very justly distil* " guishes it from la chaleur d'inflammation. The sensation in truth is as M different as touching a very hot piece of dry wood and dipping your " finger into tepid spirit of hartshorn." Frank also observes of the heat in typhus, " same manifeste acer diei- " tosque urens. Dr. Wright caffs it a biting heat (Annals of Med. vol. 2.) It was re- marked, when speaking of intermittents, that Galen makes a similar ob- servation respecting the heat in some of them. * Even the hydrophobia has been known to supervene towards the ter- mination of malignant fevers. t.If the respiration and deglutition be free, Dr. Fosdyce observes, tht prognosis is seldcm bad, although tlie other symptoms appear alarralnfr CONTINUED FEVERS. MS* The patient complains of thirst,* the appetite is impaired or wholly lost; ancl nausea and vomiting are frequent symptoms at an early period. The matter rejected is frequently a viscid, col* ourlcss transparent fluid, without much taste or smell ; an .astonishing quantity of which is often discharged in fevers. It is frequently mixed with, and sometimes the matter discharged almost wholly consists of, bile ; often in a very acrid state, espe- cially in the fevers of warm countries.! The body, as in other fevers, is generally costive, except ther* be irritating matter present in the intestines, and the patient is often troubled with flatulence and spasmodic contractions of the bowels. A little before death indeed, an ichorous or bloody di- arrhoea frequently occurs, without any evident cause ; this is al- waysoncof the worst symptoms. The prognosis is desperate, if from the highly putrid and offensive nature of the stools com- pared a-, ith other symptoms,! we have reason to believe that soma part of the intestines is mortified ; a frequent accident in the worst forms of typhus. The appearances of the urine as the fever advances, are vari- ous. Sometimes it is pale or limpid, which is never a favoura- ble appearance ; sometimes high coloured, and turbid, often giv- ing a good deal of uneasiness while it is discharged, which is sometimes a favourable appearance, and is never to be regarded as unfavourable. The same cannot be said of the urine when it appears brown, and deposits a matter like coffee grounds. This is oAving to an admixture of blood, and is uniformly a bad symp- tom. The urine is sometimes tinged with yellow, the effect of bile in the circulating system. It sometimes deposits a late- ritious, or branny sediment; these have been termed the critical sediments, and their appearance is generally, though not univer- sally, a favourable symptom. It has sometimes, indeed, been found-, a very fatal one.|| These sediments have obtained much * Not to complain of thirst, when the mouth and fauces are very dry, is an unfavourable symptom, as it generally denotes a considerable degrea (.f insensibility. In the low nervous fever however, even when the sensi- bility is not impaired, there is often no thirst. There is often no thirst, Frank ooserves, except f^r wine, which alf patients in this fever desire. ' t The black vomiting, a symptom so much dreaded in the fevers of sultry cumates, in which the matter discharged resembles coffee grounds, is tile consequence of a very vitiated state ot die bile, which assumes this appearance. When the progress of tire fever is rapid, Dr. Jackson ob- serves, tins matter is often as black as soot. When the progress is more gradual, it is not so dark, and often of a greenish colour. The bile in these c- ^ These Avifl be pointed out at length when we consider symptomatic »u " cSfe PrVL!nninS's Observations on the Yellow Fever of America, ia toe 2d vol. of Essays and Observations, Physical and Literary. Vol. L U J 54 CONTINUED FEVERS. of the attention of physicians, ancl have given rise to some very ill-founded hypotheses. I shall have occasion to speak of them at greater length, in considering the crises of fevers.* It sometimes happens in typhus, that the urine is suppressed, or passed in small quantity, although the bladder is distended. This is an unfortunate accident, as it always proves the cause of much irritation. Sometimes it is suppressed without pain or' distension ofthe bladder, which denotes a suspension of the se- creting powers of the kidneys, and affords a more unfavourable prognosis. The skin for the most part is dry ; sometimes a moisture is observed on it, particularly in the morning, and while this con- tinues, the symptoms often suffer an abatements In some cases a freer discharge by the skin takes place, but this symptom with the manner in which we form the prognosis from it, will also be considered at some length when we speak ofthe crises of fevers. It may, according to the circumstances which attend it, afford a very good, or very bad, prognosis. I have already had occasion to observe, that hemorrhagies are generally to be regarded as unfavourable in typhus. Hemorrha- gies from the eyes and kidneys have already been mentioned-! It is not a much better symptom when blood flows from the sto« mach and intestines, occasioning a vomiting of blood, and tinging the stools with a dark red, or blackish colour. There is, perhaps, no hemorrhagy which may be regarded as affording a more un- favourable prognosis in typhus, than that from the pores of the skin; which is not an uncommon occurrence in the worst forms of the complaint. The blood in these cases is particularly apt to flow from blistered parts, from old sores, or wounds, although quite healed up, from the holes, for instance, made in the ears, for earrings; from places where the patient on former occasions, * In particular epidemics the urine has assumed a variety of uncommon appearances, probably depending on some affection of the urinary organs, but none of these have been veiy distinctly marked. Thus, Dr. Chisholm observes, the urine was sometimes green, sometimes inclining to black, and of an oily consistence. Those which have been mentioned are the more common changes which happen in the urine in the'proeress of fever. Dr. Foroyce has attempted to describe a state of the urine which he re- gards as peculiar to malignant fevers, and his account is probably accu- rate ; but the circumstances which characterise this state of the urine do not admit.of being sufficiently defined to enable common observers to dis- tinguish it The urine hats a more viscid appearance than common; is frothy, browner, and not absolutely transparent, although there is no " cloud or sediment." Dr. Fordyce's 3d Diss", on Fever, part 1. t In malignant fevers " the sweat if there be any tinges tlie linen with a ddute icnorous appearance." Fordyce's 3d Diss, on Fever. «• *P£LiTi"g/bsei?uf °*the M°°dy urine in typhus, that he always found the admixture of blood become less, when the pulse acquired air degree of fulness, and again increase as the pulse sunk; denoting hoi j&uch such hemorrhagies depend on a debilitated state of the system CONTINUED FEVERS. 155 had been let blood, 8cc. In the worst cases of malignant fever, indeed, blood, or rather a thin serum, in which more or fewer of the red globules are broken down and suspended, seems some- times to run from almost every surface ofthe body, whether ex- ternal or internal. There are certain hemorrhagies, however, which now and then even in typhus prove salutary ; the most favourable of these is the cpistaxis. This indeed is often a bad symptom, as well as the hemorrhagies just mentioned, especially when the blood falls only in drops; when* it flows, more freely, it has sometimes been attended with a sudden and favourable change in the complaint. Other hemorrhagies, enumerated among the symptoms of sy- nocha, also occur, though less frequently, in typhus. These are not so often favourable as the epistaxis, but they are never so much to be dreaded as those which more peculiarly belong to typhus.* Hemorrhagies will be considered among the other crises of fever. • It sometimes happens in typhus, that the blood which floAvs from the vessels of the skin is detained beneath the cuticle, giv- ing the appearance of small round spots, which have been termed petechix. So frequent are petechix in the typhus gravior, that this fever has got the appellation of typhus petechialis, But ty> phus, (it was observed more particularly in the Introduction) often appears in its very worst forms, unaccompanied by this symptom. Petechia occasion no elevation of the cuticle, so that they are seen, but not felt. They are red, brown, or blackish ; the darker . the colour, the more danger they indicate. Their shape is also various; in general they are circular, at other times running into * Dr. Fordyce, in his 3d Dissertation on Fever, gwes the following ac- count of the state of tlie blood in malignant fevers. It is the best I have inet with. " At the beginning, when the putrefaction has not gone to any " great length, if blood should happen to have been taken from the arm, * the coagulum is loose and easily broken, the serum being hardly of a 44 browner colour than common. Sometimes, when tlie depression of " strength is not very great, the blood retains this appearance during the * whole course of die tihease. * * * 44 If there is greater depression of strength, and by consequence putre- " faction is in a greater degree, the serum becomes of a browner colour. " In a still greater degree, it is red; in this case, on examining tiered par- 44 tides with a microscope, many of them are found diminished in size, and ** not regular spheres, or oblate spheroids; some have the appearance of *' being broken in two, and look like half moons; but most of them retain 44 their healthy appearance. If the putrefaction gees on still further, there " is hardly any distinction between serum and coagulum; if still further, 44 the coagulable lymph forms a kind of bag, leaving the serum on the 44 outside distinct. In the su!§stance of the bag itself there is no intermix- 44 ture of led particles, so that it looks like the buff which is on the surface 44 of tlie coagulum in cases of general inflammation; but within this bag a 44 red fluid is contained, which upon being examined with a microscope; 44 *kews the red particles of a variety of forms." 156. CONTINUED FEVERS. each other they assume various forms. They vary from a size scarcely perceptible to that of a shilling, and arc sometimes even larger. Petechia; generally make their first appearance on the neck, breast, and back; they more rarely appear on tlie face and extremities, except on the inside of the arm, where the skin is tender, ppd about the wrist. They are sometimes so crowded to- gether, that at a little distance the skin appears uniformly reddish., In other cases they are thinly scattered. Petechix generally ap, pear before the end ofthe second week. They are generally, but not universally, an unfavourable symptom. There are instances ofthe febrile symptoms abating on their appearance.*. Instead of petechia the skin is sometimes covered with blotch-' es of a larger size, and generally of a purplish colour, termed vi- bices; at other times it is marked with streaks or stains of dif- ferent colours, which sometimes cover almost the whole body,i particularly the breast, and often give it the appearance of marble,. variously coloured. These are symptoms which indicate much danger. The dan- ger however is not always proportioned to the number ofthe pe- techias or vibices. It is usually the greater* the earlier they ap- pear. Ramazzini observes, that those of his patients in whom they appeared on the first day, almost all died. Petechias do not always continue through the whole course of the disease, but sometimes disappear in a few days; in other cases they disap- pear for a short time, and then return. They have been observe ed to continue, hoAvevcr, not only during the whole course of ihe:j disease, but for a considerable time after every other symptom of i it had. disappeared, There are some petechia: (Strack remarks)..! which var.bh in three days; others remain during the whole disease and after death ; while others remain for a considerable,.-i time after the fever has been happily terminated. , Petechia sometimes, though much more rarely, appear in sy- ndcha. The reader will find cases of this kind in Eller de Cog- r nos. et Curand. Morbis, and Dr. Grant's Treatise on the Fevers ' most frequent in London.t ,; f I shall afterwards have occasion to make some observations on the particular species of synochus, which this symptom characterises. t Petechia: sometimes appear unaccompanied by fever of any kind ■ For cases of this kind the reader may consult the inaugural Dissertations • of *Dr. EdAvard Grasr and Dr. Adair, Dr. Grant's Treatise just alluded . to, Dr. Duncan's Medical Facts and Observations, and the last vol. cf ' iiisiCommentaries in which there are four cases of this complaint. It is' ' also mentioned by ether wri'.e is. It lu.s only la^.-h been known in this c< untry. This disease has received a variety cf appellations : Petechia: sine febre, Petechiair;s.os, £x. It bcldhgs to'the third order of Dr. Cul- len's third class of d:seases, the Impet'iabi-s. It is often accompanied with, a tendency to hemorrhagy in dmvp.pt parts cf the body; the com- plaint itself indeed is to be regarded a-; Aery nearly allied to hemorrhagy. ' It baa sometimes disappeared with a flow of sweat, lasting for several days, more frequently v.!' .• dt any remarkable crisis. In some cases it has proved fatal. CONTINUED FEVERS. isr ■ When Petechias and the worst kinds of hemorrhagies or other symptoms'dene-ting extreme debility appear, there is generally a considerable tendency to mortification. The sweat and other secretions have a putrid smell, and even gangrene occurs spon- taneously. It is then most apt to appear on the nose, lips, cheeks, fingers, and sometimes attacks a whole limb the hands or feet be- coming black,* and the gangrene now and then extending as high as the elbow or knee. The extremities thus affected become cold, and often remain in this state for many days before death. In general however mortification is not spontaneous in typhus, but the consequence of slight injuries and then it may occur in any part of the body, although it is still, most apt to appear in the ex- tremities. I need hardly observe, that this tendency to mortification, or in other words to the extinction of the powers of life, affords a very unfavourable prognosis. Notwithstanding Dr. Miller, in his account of the diseases most prevalent in Great Britain, and some others, have maintained that a degree of mortification appearing on the ends of the fingers, is to be regared as a favour- able symptom in bad kinds of typhus.t Patients in this fever often groan, and seem uneasy, yet are unable to explain or point out the seat of their uneasiness. This is an unfavourable symptom, not only denoting a considerable de- gree of stupor, but indicating the presence of an irritation, which cannot fail to increase the danger. It is the business of the attendants to discover the source of this irritation, and if possible to remove it. It often proceeds from the urine or faeces being too long retained, but very frequently from excoriations, in consequence of the patient having lain too long in the same posture. This, in cases where the tendency to mortification is considerable, is often attended with very melancholy effects. Instances occur, in which, after escaping from a dreadful fevei-, the patient at a time when he begins to consider himself out of danger, discovers a mortified sore on some part of the body, which baffles all the succeeding care of his physician. Accidents of this kind warn us, to have the parts on which the patient rests examined from time to time, and when any degree of redness appears, if possible to make him change his posture. When he is so weak that he can lie only on the back, all that can be clone is, to make the bed as soft as possible, and defend the parts on which he chiefly rests by proper plasters, f.ut such is the prone- ness to mortification in many cases of typhus, that no care can prevent it. * Huxham on Fevers, Frank's Epitome de Curand. Horn. Morb. Vo- gel de Cog. et Cur. Morb. ike. Vogel particularly notices spontaneous mortification in typhus, and points out the parts of the body it is most apt to attack. fit must be admitted,, that in some rare cases tlie appearance of gangrene has been attendee! with a favourable cluuijje, the fever abating soon after it. 158 CONTINUED FEVERS; Typhus sometimes terminates in ten or twelve days, or within that period ; if it be protracted for a longer time, the symptoms usually suffer but little change during a considerable part of the disease. When it is protracted beyond the 14th day, without the more alarming symptoms of debility shewing themselves, the prognosis is generally good. Dreadful as this fever often is, it sometimes appears in a very mild form. Those who have been exposed to the contagidd or other causes of typhus, are sometimes affected with alternate heats and chills, listlessness and debility ; yet are never so ill us to be confined to bed ; and these symptoms, after teazing the pa- tient for days, sometimes for weeks, often wholly disappear. The mildness of the disease however at its first appearance, by no means assures us that it will not become serious. The worst forms of typhus are often preceded for several days by very mild symptoms.* Between the worst and miidest forms there are in- numerable degrees of this complaint, which insensibly run into each other. If the case is about to terminate fatally, the symptoms which have been enumerated denoting extreme debility, shew them- selves gradually. Cold viscid sweats appear on different parts of the body, or the colliquative diarrhoea, which has been mentioned as a frequent forerunner of death, supervenes ; and the patient) reduced to the last stage of weakness, either calmly expires, oris carried off by convulsions. ,; When, on the contrary the event is about to prove favourable, the worst symptoms either'do not appear, or if they have ap- peared begin to abate ; and the state of the patient is sometimes evidently changed for the better in the space of a few hours.f After each succeeding remission, the symptoms return with di- minished violence, till the fever is wholly removed, leaving the various functions in a state of debility, from which in general they soon recover, ancl often acquire a degree of vigour superiourto what they possessed before the attack of the fever. In many cases however the debility which remains after long protracted fevers is the source of fatal diseases, of the various * " But I can discover no symptom which may at all times be regarded u as a certain and infallible forerunner of this complaint; for at first it 44 often appears very trifling, and its symptoms at an early period are 44 sometimes so slight, that even the sick themselves cannot be persuaded " that they labour under any disorder, but continue to walk about for sev- " eral days." See a paper by Henricus Mains, in Haller's Disp. ad Morb. Hist, et Cur. Pert. There are many good observations in several papers on fever in the fifth volume of this work. t It sometimes happens, though much more rarely, that the fever from being alarming is wholly removed in the space of a few hours! When the change is so sudden, it is generally attended with some of the symptoms that have been termed critical, which will presently be con- sidered. CONTINUED FEVERS, U9 kinds of dropsy, of phthisis, or any other complaint to which the patient happens from other causes to be predisposed. For the circumstances which usually act as predisposing causes of a va- riety of complaints, often become exciting causes in debilitated states of body, however induced. It is not uncommon for those fevers, in which much debilityr prevails, to be followed by a permanent derangement of some of the functions. The patient has been known to remain deaf Dr blind. More frequently these senses are only impaired. The voice also is sometimes so much altered, that it never recovers its usual tone, and is now and then wholly lost. It is not un- common for the judgment to remain deranged, particularly after fevers in which the delirium has been obstinate. From this melancholy consequence the patient frequently recovers, unless there be an hereditary disposition to mental derangement. A set of symptoms common to all kinds of fevers still remains to be considered; those which attend the more sudden changes from fever to a state of health,* and which have on that account been termed critical. SECT. III. Of the Crises of Fevers. OF the symptoms which attend the more *6udden changes from fever to health, the most common is what has been called the critical deposition of the urine. During continued fever the urine is usually passed in small quantity, is sometimes high coloured, more frequently pale, and for the most part without much cloud or sediment. As tho symptoms abate, it i3 passed in greater quantity, and generally deposits a more or less copious sediment. This sediment con- sists either of red crystals, which usually do not appear till from 4 to 24 hours after the urine is passed, and fall to the bottom, leaving it limpid ; or the sediment consists of a reddish or whitish matter which generally appears within an hour or two after the urine is passed, and only falls in part to the bottom, the urine re- maining turbid. The latter of these sediments has been ternv ed furfuraceous or branny ;f the former, from its resemblance * It is only at an early period that fevers terminate suddenly, either favourably or otherwise. The termination of protracted fevers is usually gradual. 44 When the nervous fever," Dr. Moore observes, 4< terminates 44 favourably before or at the end of the second week the crisis is gene* " rally obvious ; but when that happens at a later period, particularly if 4' after the third week, the favourable term is less evident, and sometimes " several days pass during which the disease abates so gradually, that the 44 most experienced are in doubt whether it abates or not." t The white sediment when dried is also found to consist of roitHjte «rysta]fc 160 CONTINUED FEVERS. to brickxlust, latcritious ; but the last term has not been Used, in a very definite sense. Sometimes both tiicse depositions take place from the s mie portion of urint% But when therC 1S ™ of the one, there is generally but little oi the other. These sediments have long been and still are by some regarded as a morbific matter, which was the cause of the fever, and to the discharge of which the abatement of the symptoms is to be attri- buted. But the truth is, that both sediments are almost constant- ly met with in greater or less quantity in the urine of persons i:i health. I had occasion some years ago to make observations on tlie urine, with a vieAv to determine the modes of life which dispose this fluid to deposit Avhat Schecle calls the lithic acid, which is the same with the brick coloured sediment which appears in the urine of febrile patients.* From these observations it uppears, that the red coloured sediment is most copious when, from an acescent diet or a debilitated state of the digestive powers, there is much acidity in the primse vix, or when the perspiration is checked, in consequence of which, the acid, which ought to have passed by the skin,f is throivn upon the kidneys. It is farther sheAvn, that if while the perspiration is checked, the action of the kidneys is also debilitated, the acid causing the deposition of this matter from the urine accumulates in the sys- tem, and is thrown off by the skin and kidneys when their vigour is restored; and that in proportion as the perspiration is free, the less of this acid passes by urine. Thus the appearance of the lateritious sediment in the urine is merely a symptom of return- ing health, but generally indicating a less free perspiration than natural. •The other, the cream-coloured or furfuraccous sediment, which also now ancl then assumes more or less of a red or rather a pink colour, but has an appearance very different from the former, was found most copious in the urine of those who used an alka- lescent diet, or in whom the perspiration was unusually free, so that any acid received into, or generated in, the body was passed chiefly by the skin. This sediment therefore, like the former, is merely a symptom of returning health, and particularly indicates the renewal of a free secretion by the skin, which in fevers is generally a favour- able symptom. But whether a favourable symptom or not, It is still attended with the same deposition from the urine. In some fevers termi- nating fatally there is an unusual tendency to sweat, which only * An account of these observations Avas published in 1792. t It is ascertained by experiment, in the Treatise alluded to, that a» acid passes oft. even by insensible perspiration. CONTINUED FEVERS. 161 tfxhausts the strength. In these, the critical depositiohv of the urine is constantly present, but without bringing relief. This is the case in hectic fever. I have observed this deposition in other cases where there were ni^ht sweats without any lever. Nay I have found on repeated tv: .Is, that I could at pleasure occasion the appearance ofthe furfuraceous sediment in the urine of healthy people, by promoting the perspiration by small doses of tartar emetic or* Dover's powder. In short all that we can infer from it in fevers is, that a relaxation of the skin has taken place, that tlie secretion by this organ is restored. These appearances in the urine therefore, at the favourable termination of fevers, are certainly not the cause, but the consequence, of recovery.* ' ' Next to the critical (deposition of the urine, there is no symp- tom which so generally attends the change from fever to health as S weal in;;. This we found to be the crisis of intermittents, ac- companied however as sweating generally is, whether in health or disc.se, with a sediment in the urine. Even continued fever is seldom terminated favourably without some degree of moisture appearing on the skin. The crisis in synocha, says Hoffman, is in most cases a profuse sweat. Dr. Grant remarks of the syno- chus, " Nor do I find the crisis ever perfect till the night kindly " sweats begin to Aoav ; and Dr. Huxham declares, that he never saw, " amalignant typhus cured till more or l**ss of sweat had issued." It is surprising that the best effects are sometimes pro- duced, even in those fevers in which debility prevails most, by profuse and long continued SAveats. Dr. Dom.".' ?>'Iunro remarks, tint in the petechial fever the sweat often continued for three or four days with the best effects. Another remarkable peculiarity of this fever (the petechial) says Hoffman, is the profuse cold sivcats, of an acid smell, continuing for several days and nights, and proving a salutary crisis.f * The fallowing are the only appearances of the urine, if Ave except those it assumes in consequence of morbid affections cf the urinary organs, wh'ch can lie distinctly marked, namely, the pale urine Avithout cloud or sediment; the pale urine with a light cloud appearing a few hours after it has been passed; the high-coloured urine remaining clear or having a "'.Wit cloud formed in it without sediment; the high-coloured urine re- maining clear «,r having a light cloud formed in it and depositing usually a considerable time (from 4 to 24 hours) after it has been passed a red c rystalised sediment; the high coloured urine becoming turbid after it has l>een passed for a short time, (from one to five or six hours) and deposit-, ing alight coloured sometimes reddish sediment, now arid then (after the urine has stood for a longer time) mixed with more cr less, never with much, of the red crystahsed sediment; and in almost every complaint, as'well as in perfect health, the urine occasionally assumes all these ap- pearances, t/.ir :i is the foundation of the practice of tiiose empirics, who pretend to determine tlie complaint under which their patient labours by* inspecting the urine. t He adds hoAvevcr, that these swears, although proving critical, always indicate much debility, and that if the patient's strength be not supported Avhile under them, he frequeutly sinks when on the brink of recovery. ; Vol. I. W 162 CONTINUED FEVERS. From these facts hoAvcver avc are not to draw an inference, which long misled physicians, and proved a source of much mis- chief; that the solution of the fever is to be wholly attributed to the flow of sweat, and that could this symptom by any means l« induced, it would always prove equally beneficial. To this hypo- thesis, besides other erroneous parts of practice, we may trace the employment of the hot regimen in fevers; an error so fatal, that it mav be seriously questioned, whether the medical art, du- ring its preAalence, did more good or harm in these complaints. It has just been shewn that the critical sediments in the urine are to be regarded, not as the cause, but the cons«quence, of re- covery. Critical sAveats are to be viewed in nearly the same light. Nothing would be more hurtful than any means tending to check a sweat which is attended with an abatement of the symptoms, and it is even proper, as will be pointed out more par- ticularly in considering the treatment of fevers, to use innocent means to promote such SAveats ; but to endeavour to force out sweats by warmth and heating medicines, is universally pre- judicial. The wished for crisis is never obtained in this way, and the attempt has often cost the patient his fife. Even spontaneous SAveats in fevers are not always to be encou- raged. When, as sometimes happens, they occur at an early period of the disease, and continue without relieving the symp- toms, they indicate danger, exhausting tlie strength without prov- ing critical. Nor are those sweats to be encouraged which are viscid and partial. Unless the SAveat be thin and universal, it rarely proves beneficial. SAveatingnot only does not always afford a favourable prognosis, but is sometimes among the most fatal symptoms in fevers. Sweat running copiously from the head and neck is mentioned as a frequent forerunner of death in the yellow fever.* It is of the same fever that Dr. Linning observes, that the urine often shews the critical sediment on the very first day, which he uniformly found a bad symptom, and the more copious the sediment was, the worse, he observes, was the prognosis?! One of the most fatal fevers of which we have any account is the Ephemera Britanica, described by Cains; the chief symptom of which was a profuse flow of sweat, from, which it received the appellation of Sudor Angiicus.i Except the critical deposition from the urine and sweating, there is no symptom which oftener attends the more sudejen changes from fever to health than diarrhoea. If a diarrhoea, super- * See Dr. Jackson's observations on this fever. ■ t* See Dr. Linning's letter to Dr. Whytt, on the yellow fever of South America, in the 2d vol. of the Eisavs and Observations. PU deal and Literary. X See Caius de Ephemera Britanica, CONTINUED FEVERS. 16S vene on any of the critical days, Hassenhorl* observes, we must be careful to do nothing that may check it; and Hoffman remarks, that in his practice he has more frequently observed a diarrhoea critical in the petechial fever than cither sweat or hemorrhagy. In many epidemics there is a peculiar tendency to terminate in this way, and then the discharge is generally more or less dys- enteric. It is in autumn, the season in which dysenteric affec- tions are apt to appear, that fevers are most frequently terminated by a discharge from the intestines.! This crisis is generally for some time preceded by flatulence, gripes, and pains of the loins. Spontaneous diarrhoea, hoAvever, is far from being universally favourable in fevers. If it occurs in typlvus, while the other symptoms are alarming, if the symptoms are not relieved by it, and particularly if the discharge is attended with much loss of strength, it is among the worst symptoms of the complaint, often baffling all our endeavours to check it, ancl proving the forerun- ner of death. This diarrhoea, which by medical writers is em- phatically termed colliquative, 1 have already had occasion to notice. Although Ave are never to expect the same effects from the ex- hibition of cathartics, which sometimes attend a spontaneous di- arrhoea in fevers, it is often useful in the synocha, for reasons which will afterwards appear, to keep up a moderate catharsis. This is never to be attempted in typhus, in which the bowels ought only to be moved, for the regular expulsion of the faeces. Vomiting may also be enumerated among the crises of fevers ; it never proves critical, however, except at, or very soon after, the commencement of the disease ; then, whether spontaneous or induced by art, it sometimes stops the progress of fever. The crisis which next deserves attention is that by hemorrhagy. A spontaneous flow of blood from the different parts of the body is frequently intended with an abatement, or total removal of the symptoms of synocha ; and, what may appear surprising, some- times of those of typhus, that is, of those fevers whose charac- teristic feature is debility. As physicians inferred from tlie critical deposition of the urine, that fever is owing to the presence of a morbific matter in the blood, and that this morbific matter must be thrown out of the body before the fjver can be removed; and as they inferred from the relief obtdned during critical sweats, that this matter may be thrown off by the skin ; so they inferred, from the abatement of the symptoms Avhich frequently attends hemorrhagies, that it * See his Ilistoria Febris Petechialis. ! In autumn, Quarin observes, fevers are more frequently relieved by a spontaneous purging than at ether bta^.i^. 164 CONTINUED FEVERS. may be thrown cut cf »hc body by venesection. Nor did the very obvious objection, that although fever be admitted to arise from the presence of morbific matter in the blood, a partial abstraction of this fluid cannot free the system of a matter diffused through the Avhole mass, prevent them from recommending venesection in all kinds of fever. If there be any practice which has been more baneful than the hot regimen, it is the indiscriminate use of blood-letting in these complaints. This subject it will soon be necessary to consider more particularly ; it is sufficient here to observe, that repeated experience has at length convinced physicians, (at least those phy- sicians who condescend to take experience for their guide,) that the effects of venesection and a spontaneous hemorrhagy in fevers, are often so different, that the favourable change, which fre- quently attends the latter, must be attributed to something else than the mere loss of blood. And as we certainly knoAv that the critical depositions of the urine, and have often reason to believe that critical sweats are the consequence, and not the cause, ofthe favourable change which attends them ; so we have reason to be- lieve of spontaneous hemorrhagy, that partly,, at least, it is owing to the general relaxation of the extreme parts of the vascular sys- tem, which takes place in tlie change from fever to health. The loss of blood in critical hemorrhagies, indeed, is often too trifling to be supposed capable of any considerable effect. Of hemorrhagies, that from the nose is most frequently critical. It is generally preceded by some of the folloAving symptoms. An unusual redness, of tlie eyes, sometimes an increased secre- tion of tears, a sense of weight in the temples, dimness of sight," pain of the head, generally, Quarin observes, of the occi- put, itching of the nose, and the pulsiis dicrotus, regarded by physicians as one of the chief symptoms portending a critical he- morrhagy in fevers. In this state of the pulse, which is also called rebounding, the artery seems to strike the finger double. Before hemorrhagies in general, the patient usually complains of heat, tension or pain in the part from which the blood is about to flow. The worst species of hemorrhagies which occur in ma- lignant fcve.ro, however, arc not preceded by any other symptoms tlii.li those of general debility, and never prove critical. Critical hemorrhagies, it has been observed, are most frequent in those fevers, which arise from gluttony, the abuse of intoxi- cating liquors, or suppressed discharges. Eruptions of various, kinds now and then prove critical in fe- vers ; this is scmctim.es, but not often, the case with the erup- tions enumerate 1 in the Introduction as characterising particular species of synochus. Even the appearance of petechia is some- times attended with an abatement of the febrile symptoms. Of these eruptions the aphthx most frequently bring relief.* * " Ad Aphthas," Sydenham observes cf a continued fever which raged CONTINUED FEVERS. 165 Aphthae, however, arc far Gram always- being a favourable" ap- pcaiauce in fevers. When light coloured, and accompanied with a considerable flow of saliva, they arc often, attended with an abatement of -the symptoms. But when there is little flow of saliva, and particularly when the aphthae are of a dark colour, they are never a favourable, and often a very fatal symptom. An increased secretion of mucus from the fauces, or of saliva, al- though there are no aphthae, is often a favourable symptom in fevers.* The latter sometimes amounts to a salivation, and has been known to prove critical. Bo'th Sydenham! and Huxham| relate cases of this kind. An eruption of another kind, more frequently than any of these just alluded to, attends the favourable termination of fevers.; a scabby eruption appearing about the mouth or behind the ears W One of the most remarkable crises of fevers, is a swelling and suppuration of glandular and other parts of the body. This crisis rarely happens in the synocha. The parotid glands are the parts most commonly affected. They sAvell a'nd become inflamed, and the event, of the fever seems often to depend on the dis- charge of the matter generated in them. It has generally been found the most successful practice to lay them open as soon as, or even before, any fluctuation can be perceived in them. " If the disease," Sir-John Pringle observes of typhus, " terminates in a suppuration of the parotid glands, " one caution.only is needful, which is to open the abscess soon " without waiting for a fluctuation, or even a softness of the " tumor, which, may never happen. The pus bring here so very {; viscid, that after it is ripe the pai'twill feel as hard, as if the- " suppuration had not begun."} I have heard Sir Walter Farquhar observe, that when he at- in London in 16G9, 70, 71, 72, "cum jum diiccvum mediiaretur, erat " prnpensior." (See Sydenham De Ft.-I?rii>us Coi tinuis). The favoura- ble termination of that species of synochus, Avhich is attended with the miliary eruption, is often preceded by tho appearance of aphthx. Some- l i.ncs," Dr. Mead observes,- (see Mead's M.ir.ita et Precepta Medica) the ■mutter of the.fever occupies the fauces in the form of aphtha, at the same lime that it appears in die miliary eruption en tlie skin. Li they are white, and attended with a copious floAV of saliva, fucy do not portend r.angcr but safety. Dr. Grant repeatedly cautions against repelling aphthsc Avhen they appear in fevers, and thinks that eA'en astringent gargles are hurtful. * The former of these is mentioned as having generally been attended Avith an abatement of tlie symptoms in the late dreadful fever of Phila- delphia. X See Sydenham de Febribus Continuis. i See Huxliam on Fevers. Vogel obsen'es, that intermittents are sometimes cured by a salivation. || Rush on the Yellow Fever of Philadelphia, a..J Chiiliolm en that of Grenada, &c. § Sir John I'ringle's Observations on tlie Dis-ea^e* of tlie Arm}'. 166 CONTINUED FEVERS. tended a regiment on the continent, there appeared among thft troops a violent fever accompanied with a swelling ofthe parotid glands, which never came to suppuration. Almost every patient attacked with this fever died, till it occurred to l.im that an in* cision ofthe enlarged gland might prove serviceable ; from which*. he experienced the best effects. ' Several cases related by Dr. Donald Monro,* prove in the most satisfactory manner the advantage derived in fevers from the free suppuration of the parotid glands when swelled and in- flamed. " Swellings of tlie parotid glands," he observes, " ap- " pcared in many subjects towards the decline of the fever, which " came to suppuration and proved critical. In two only, out of " those I attended while in Germany, they came on early in the " fever, but did not suppurate ; both patients died. All the rest " recovered, except an old man, an invalid of Bremen."! Dr. Monro applied poultices and gummous plasters to the in- flamed glands, and as soon as the presence of matter could be perceived, he laid them open. The cases in which the patients died before this happened seem to point out Sir John Pringle'a mode of treatment to be preferable, as it does not appear that any bad consequences followed the laying open of the inflamed glands, .at an early period. In some epidemics however it has proved otherwise, as appears from the observations of Acrel, in the Memoirs of the Royal Aca- demy of Sciences at Stockholm. He often met with abscesses in different parts of the body in malignant fevers. At first he opened them as soon as matter was formed, the consequences of which were, that the strength sunk, the fever became worse, and the patient generally died within eight days. In some cases, after the fluctuation ofthe matter was distinctly perceived, a purulent discharge from the intestines, fauces, or nose supervening, the tumors subsided, and the patient got well. The physicians endeavoured to promote the termination which nature pointed out. They gave gentle laxatives as soon as the matter was formed, during the operation of the third of which, it is observed, the stools were generally mixed with purulent mat- ter, the tumors subsided, and the fever disappeared. These swellings sometimes appear in the arm-pits, or in the groin, and sometimes in the testicle. Instances of all of which the reader will find in Dr. Donald Monro's Observations on the * See Dr. Monro's Treatise on the Diseases ofthe Army. X This case demonstrates in a striking manner the connection between the suppuration of the parotids and the solution of the fever. A swel- ling appeared on the right side, which came to suppuration and proved critical. The fever hi a short time retunied; another swelling appeared on the other side, which came also to suppuration, and the fever again eeased. The patient afterwards died hectic, in consequence of the pro- fuse secretion from the sores. CONTINUED FEVER* 16* Diseases of the Army. Dr. Rush observes, that glandular swell- ings frequently accompany the yellow fever. He never saw them come to suppuration, but generally found that they tended to afford a favourable prognosis. Dr. Chisholm however observes* that they were among the unfavourable symptoms of the late dreadful fever of the West Indies, which differed in many respects from the common yelloAv fever, particularly in being accompanied, at least in Grenada, with pestilential eruptions.* The last symptom I shall mention, as deserving a place among the crises of fever, is shivering. When this occurs in the prog- ress of continued fever, it is sometimes followed by the hot stage, and other symptoms of a paroxysm of an intermittent, which proves the termination of the continued fever, and often the com- mencement of an ague. " The certain sign," Dr. Grant! ob- serves, "of turgid matter after decoction, is that sensation, which " we distinguish by the name of a chilly fit. After this, the pulse " will rise and the heat increase ; nothing ought then to be at- " tempted but dilution, which nature commonly points out by an " increase of thirst. This state frequently lasts a considerable "time, but gives no cause for uneasiness; some evacuation will " certainly follow, and that evacuation, whether it be 6Aveat, saliva, " urine, stools, or eruption, wil' infallibly prove, in some measure, " critical." As it was formerly observed, that when an ague becomes a con- tinued fever, it is to be treated in the same way as if it had been so from the beginning; it may now be observed, that At hen a con- tinued fever becomes an intermittent, it is to be treated like other intermittents, without any regard'to the form it at first assumed. * A symptom of a very peculiar kind sometimes appeared in this fever, and often proved critical. " About the same time," Dr. Chisholm ob- serves, " another symptom appeared in many instances, which, were is " not for its singularity, might be considered too minute to be mentioned " among those which distinguish tlie disease. Its feingularity arises from " the silence of other writers concerning it, andfrom its appearing in the " present instance to be critical. About tLe ei*d of the second day the " patient beginsio complain cf a violent pain in his testicles ; he says he " teeis a contraction of the spermatic cord. On examining tlie testi- " cles they appear much lessened in size, and drawn up towards tlie " abdomen, and the scrotum appears remarkably flaccid and empty. " The surface g man, do not diminish the temperature of his body, unless " the temperature of the bodies applied be below 62 degrees. " From hence it appears, that the absolute cold in this climate " does not act on the living human body, unless the cold applied " be below the degree just now mentioned.* "It appears also, that the living body being surrounded by air " of a lower temperature than itself, is necessary to its being re- " tainedin its proper temperature of 98 degress ; for in this cli- " mate every temperature ofthe air above 62 degrees applied to " the human body, though still of a lower temperature than itself, " is found to increase the heat of it.! And from all this it ap- " pears, that the absolute power of cold with respect to the hu- u man body is very different from what it is with respect toinani- " mate bodies. " The relative power of cold, with respect to the living body, V is, that power by which it produces a sensation of cold in it; " and with respect to this it is agreeable to" the general principle * There is an evident inaccuracy in this statement, because the velocity with which caloric is abstracted by any medium, is not only in an inverse ratio toils temperature, but also in a direct ratio to its density. The tem- perature ofthe body is not diminished by air at the temperature of 62° ; but it is diminished by water or quicksilver at the eame temperature, be cause their density is greater than that of air. I shall here, and in other places, follow chemical writers in the use of the term caloric; confining that of heat to the sensation produced by calo- ric. Expressing by the same term both the sensation and that Avhich causes it, is a constant source of inaccuracy. The same objection applies to the common use of the term cold. We want a term expressive of the abstraction of caloric. ! There is also an inaccuracy in this statement. For the increase of tern - perature in this case is almost wholly confined to the surface. It appears from a variety of experiments, particularly those of Dr. Crawford, Dr. Fordyce, an&Mr. Hunter, that the living body resists an increase as well as a diminution of its temperature, and that there is no temperature to which we can venture to expose the human body, which wiil raise the in- ternal parts more than a very few degrees above the natural temperature. See an account of Dr. Crawford's experiments in his Treatise on Animal Heat; of those of Dr. Fordyce, Sir C. Blagden, and others, in the LXVth volume of the Philosophical Transactions ; and of those of Mr Hunter, in his work on the Animal Economy. Mr. Hunter's experiments,.if ac- ct irate, are the most conclwjiye in favour of the body possessing a peculiar power of resisting an increase of temperature, as in them the result can- not be attributed to the effects cf evaporation. Dr. Crawibrd's experi- ments prove, that an animal disengages a less quantity of caloric in a liijdi than in a low temperature ; but if I.-Ir. Hunter's experiments are ac- curate, our bodies must possess a power of combining, as well as disenga- ging, caloric. 175 CONTINUED FEVERS. " of sensation, that the sensation produced is not in proportion « to the absolute force of impression, but according as the new " impression is stronger or weaker than that which had been np- " plied immediately before. Accordingly, with respect to tern- " perature, the sensation produced'by any degree of this, de- " pends upon the temperature to which the body had been iramc- " diately before exposed ; so that whatever is higher than this " feels warm, and whatever is lower than it feels coW ; and it " will therefore happen that the opposite sensations of heat and " cold, may, on different occasions, arise from the same tempc- " rature as marked by the thermometer. " With respect to this, however, it is to be observed, that al- " though every change of temperature gives a sensation of cold " or heat as it is lower or higher than the temperature applied « immediately before, tne sensation is in different cases of dif- " ferent duration. If the temperature at any time applied is un- " der 62 degrees,* every increase of temperature applied Mill " give a sensation of heat ; but if the increase of temperature " does not arrive to 62 degrees, the sensation produced will not " continue long, but be soon changed to a sensation of cold. In " like manner, any temperature applied to the human body, lower " than that of the body itself, gives a sensation of cold ; but if " the temperature applied does not go below 62 degrees, the sen- " sation of cold will not continue long, but be soon changed to a " sensation of heat." The paragraphs which follow in Dr. Cul- len's First Lines, respecting the manner in which cold acts on the living animal body, are omitted, as not only hypothetical but in som« parts inconsistent. In the 92d paragraph Dr. Cullen enu- merates the morbid effects of cold. " 1. A general inflammatory disposition of the system, which " is commonly accompanied with rheumatism or other phlegma- " siae. " 2. The same inflammatory disposition accompanied by " catarrh. " 3. A gangrene of particular parts. " 4. A palsy of a single member. " 5. A fever, or fever properly so called, which it often pro- " duces by its own power alone, but more commonly it is only " an exciting cause of fever by concurring with the operation of " human or marsh effluvia. " Cold is often applied to the human body without producing " any of these morbid effects, and it is difficult to determine in " what circumstances it especially operates in producing them. " It appears to me, that the morbid effects of cold depend partly " upon certain circumstances of the cold itself, and partly on cer"- " tain circumstances of the person to whom it is applied. * See note in page 171. CONTINUED FEVERS. 173 " The circumstances ofthe cold applied which seem to give it "effect are, 1. The intensity or degree of the cold. 2. The " length of time during which it is applied. 3. The degree of " moisture at the same time accompanying it. 4. Its being ap- " plied by a wind or current of air. 5. Its being a vicissitude, " or sudden and considerable change from heat to cold. " The circumstances of persons rendering them more liable to " be affected by cold, seem to be, 1. The weakness ofthe system, " ancl particularly the lessened vigour ofthe circulation, occasioned " by fasting, by evacuations, by fatigue, by a last night's debauch, * Caius de Ephemera Britanica. X Aliionius de Miliariusi Origine. CONTINUED FEVERS. 173 described as new, extremely contagious, and quite incurable by any means which they could think of. After quoting the obser- vation of C/lisson, that the rickets were only known in England' SO years before he wrote, Dr. Ferriar* observes, " the yaws, the " sibbens, and other national infectious disorders afford strong- " proofs of the variety of animal poisons ; and Mr. Hunter in his " excellent work on the Lues, has given good reason for believing- " that new poisons are constantly produced among the poor of " great cities." From these and many similar observations, it appears that Dr. Cullen is wrong in attempting to limit the num- ber of contagions to a very few species. Concerning the source of the above and other contagious disea- ses, there is but one conjecture Avhich appears at all probable- That each, though afterwards propagated by contagion, is at first produced independently of contagion, by a concurrence of causes Avhich rarely takes place. And when, at any period, it happens, that no person labors under the disease, it must of course cease to exist ; ancl cannot be reproduced unless a sufficient quan- tity ofthe contagion is preserved in fomites,! till the same causes, which first gave rise to it, again conspire. Thus contagious dis- eases may for a long time disappear, while a different combination of causes may give rise to other disorders, which will in like manner spread by their peculiar contagions. The probability of this conjecture will be strengthened by what I am about to say of typhus. Whatever be the dHficulty of tracing the source of other conta- gious diseases, it is no difficult matter to detect that of typhus. The combination of a very few circumstances, and those of fre- quent occurrence, is sufficient to produce this complaint. Typhus, that is, fever in which debility prevails, may arise in any ill ventilated and crowded place. Mr. Howel ancl others, who escaped from the black hole of Calcutta, were seized Avita this fever. Thus Dr. Lind ascribes the production of many con- tagious fevers on shipboard to keeping the hatchway shut. Typhus frequently arises in hospitals, jails, transport ships, Sec. when du« care has not been paid to ventilation. It is evident, therefore, that the effluvia of the living body, become putrid by stagnation, are capable of producing this fever.| Putrid effluvia, from any other source, also produce typhus. Thus uncleanlincss of all kinds is favourable to the production of this complaint ; and on this account such fevers generally take their rise among the poor, and among them are most fatal. " 1 * Dr. Ferriar's Medical Observations and Reflections. ! Matters impregnated with contagion. X Ii is observed, by Dr. Fordyce and others, that many brute animals are subject to typhus, when crovdcd together in ill-ventilated places! This fever has been observed to break out among hogs, and more frequent!*' among sheep. * 176 CONTINUED FEVERS. « have known a nervous fever," Dr. Ferriar observes, " which " was putrid also in manv instances, preserved in a small town for " almost two years, among the poor alone." But one of the most " satisfactory cases of this sort," he remarks a little lower, " was observed, by Dr. Heysham, at Carlisle. In 1778 and 1779, " a fever of the nervous kind raged in that city, which did not " seem to have been introduced from any neighbouring place. " Dr. Heysham with great industry traced its origin to one of the " gates which Avas tenanted by five or six very poor families." This " disorder," Sir John Pringle observes, " is incidental to every " place, ill aired ancl kept dirty, that is filled with animal steams " from foul and diseased bodies ; and on this account, jails and " military hospitals are most exposed to this kind of pestilential " infection. As the first are in a constant state of impurity, and " the latter are so much filled with the poisonous effluvia of sores, " mortifications, dysenteric, ancl other putrid excrements. Nay, " there is reason to apprehend, that when a single person is taken " ill of any putrid disease, such as the small-pox, dysentery, or " the like, and lies in a small close apartment, he may full into " this malignant fever." The confinement of the putrid effluvia is not always necessary for the production of typhus. When the cause is sufficiently powerful, the whole air of a neighbourhood may be so loaded with putrid effluvia, as to be capable of producing this fever. Senac gives an account of a malignant fever occasioned by the offal of a city being accumulated without the walls. It was re- ceived into a ditch filled with water, and while it was covered with the water, was not attended with any bad consequence ; but when the quantity increased so that it rose above the surface, a dreadful fever spread through the city and'its neighbourhood, and in the same place, where four hundred used to die yearly, the deaths were increased to two thousand.* It often happens that typhus spreads itself over the adjacent country, when the dead are left unburied on the field of battle. And Forestus mentions a feA'er ofthe same kind, which raged at Egmont, in North Hol- land, occasioned by a whale which had been left on the shore. Many more instances of the same kind might be'adduced. The putrifying effluvia of animal and vegetable matters pro- duce continued fever when the situation and air are dry, and in- termittents when they are damp.! Such is the principal source of typhus ; but in the causes of every species of fever we find a source of this ; for from whatever cause fever arises, and whatever appearance it at first assumes, it may by various accidents be protracted, and become a conta- gious typhus. * Tlie air was so loaded with putrid effluvia, that those who liA-ed near the heap of putrifying matter could not keep flesh sweet for three hours. ! Compare what is here said with what was said of the remote causes ef intermitting fever, b. 1, c. iii. CONTINUED fEVERS. i77 It is said, that typhus has been found more apt to arise among people who live much on animal food, particularly if salted, than among those who use a large proportion of fresh vegetables. This opinion, however, the result of hypothesis rather than ob- servation, appears to be ill founded. Typhus is least apt to arise when the diet is such as best preserves the vigour of the system ; and thi:; diet is different in different circumstances. Peculiarity of constitution and hattit influence it much. I shall presently have occasion to point out the states of body which predispose to, or tend to prevent, infection. It has been a favourite opinion, that certain states of the air, in- dependently of the circumstances which have been pointed out as the sources of typhus, often produce this, as well as other conta- gious fevers. This induced Sydenham to mark attentively the state of the weather, in different years, during which epidemics of different kinds raged. But after the most careful observation he was obliged to confess that he could perceive no difference in seasons in which very different contagious diseases prevailed. Van Swieten made a similar set of observations, which led him to the same conclusion. He marked down for ten successive years, three times a day, the height of the barometer and ther- mometer, the direction and strength of the wind. He also mar- ked the quantity of rain that fell, the various changes of the air, diseases, number of the sick, and of those who died. These ob- servations, like those made by every other person in the course of his own experience, prove, that certain complaints, pleurisies, quinsies, 8cc. are most frequent in certain kinds of weather > but they throw no light on the source of contagious diseases. Of the Ways in which Typhus spreads. In whatever manner typhus is produced, it is always, I may say, (instances of the contrary are so rare*) propagated by con- tagion. There are three ways in which a contagious disease may spread. 1. By actual contact. 2. Through the medium of the air. 3. By means of substances which have been in contact with,or near the sick. Concerning the first of these, little need be said. It is prob- able, that the larger the surface which has been in contact with the sick, and the longer it has been so, the less will be the chance * It is remarkable indeed, that we sometimes meet with malignant fe- A-ers, which do not appear to be at all contagious. " Sometimes," Dr. Lind observes, " one man may be seized with the petechial, or with the " yelloAv ftver, while the rest continue unaffected." Dr.Lind jives seve-; ral instances in support of this observation. » Vol. I. Y 17S CONTINUED FEVER9. of escaping infection. • Of the other ways in which contagious diseases spread, it will be necessary to speak at greater length. The air is the medium through which contagion in most in- stances perhaps is applied to the body ; since it is common for peo- ple to be attacked with contagious diseases in consequence of ap- proaching the sick, without touching them or any thing which has been in contact with them. It appears, from a variety of observations, however, that the contagious atmosphere, that is, the air sufficiently impregnated with the contagion to produce the disease, extends only for a short distance around the sick, not only in typhus, but in all other contagious disorders, certainly not above a few yards, probably not above a few feet. Contagion, however, may be conveyed from place to place by the wind, and thus the disease may be communicated at a consid- erable distance from the sick. In proof of this, many facts might be adduced ; one of the most striking on record happened on the llth of May, 1750, at the Old Bailey. The prisoners were kept for nearly a whole day in small, ilk ventilated, ancl crowded apartments ; some of them also laboured under the jail fever. When they were brought into court, the windows at the end ofthe hall, opposite to the place where the judges sat, were thrown open ; the people on the left of the court, on whom the wind blew, were infected with a malignant lever, while those on the opposite side escaped. The lord chief justice and the recorder, who sat on the lord mayor's right hand, escaped ; while the lord mayor and the rest of the bench ■who sat on his left, were seized with the distemper. Many ofthe Middlesex jury, on the left side of the court, died of it, while the London jury, who sat opposite to them, received no injury.* Some maintain, that we may often detect the presence of con- tagion in the air ; that it may be perceived by the sight or smell. Of this, however, there seems to be no proof, and much of what has been said on this subject may be ascribed to the effects of imagination. ' To this at least may be attributed what has been said of a mist surrounding those who labour under the worst kinds of fever, or of a cloud hanging over a city where such dis- orders rage. Caius observes of the Sudor Anglicus, that a dis- agreeable smell preceded the distemper, and a black cloud was seen to move from place to place as if driven by the wind, the dis- temper following the course of the cloud. Concerning the accu- * It may be owing to contagion being conveyed by the wind, that con- tagious diseases are most malignant in calm weather, the wind being a, principal means of preventing the accumulation ofthe coutagicn. It is, said, that duiing a plague at Vienna the wind did not blovv for three months ; at the end of this time a breeze arose, by which the distemper was evidently ailev iated. See Van Swieten's Comment, in Aph. Boerha*' vii. CONTINUED FEVERS. 179 *acy of observations, which so many bave had the same oppor- tunity of making, and so few have made, there must be much doubt. The smell of patients labouring under fever seems, from a Tariety of Licts, to depend on something distinct from the con- tagion. Forniies may be highly impregnated with contagioa without having any particular smell ; where the smell of the patient is strongest the contagion is often weakest, and vice versa. Upon the whole »we have reason to conclude, with Dr. Fordyce, that the presence of contagion in the air is not tobe'de- tected by any of the senses. It has just been remarked, that there Is no particular state of the weather, which, independently of the circumstances pointed out as the sources of typhus, are capable of producing this fever. It has been observed, however, that while contagious distempers rage, certain states of the air are more or less favourable to their progress. The plague has been observed to spread more rapidly in damp foggy, than in clear dry Aveather. Dr. Lind observes of typhus, that a damp air seems to increase the strength of its contagion ; Dr. Smith makes a similar observation. This has been ascribed to the contagion being diffused through the air with greater difficulty when loaded with watery vapour. It is more probably oAving to the sickly state of body which a damp air in- duces ; it checks the perspiration, disorders the stomach, and of- ten renews febrile and other complaints.* It is generally supposed, that hot weather is favourable, and cold Aveather unfavourable, to the spreading of contagious diseases; ancl this, with some exceptions, is true. It is common for conta- gious diseases to suffer a check, or cease altogether, when the winter sets in. But the worst fe\rers have often raged at the col- dest seasons. The plague did so in London, andthere have been instances of the plague suffering a check as the weather greAV warmer. There seem to be particular states of the air, not to be distin- guished by the senses, which are favourable to the spreading of contagious diseases. It appears, from the observations of Dr. Linning on the yelloAv fever of North America, that although this fever infects readily the inhabitants of a town where it rages, and particularly those lately come from the country, yet if the sick retire to the country, they do not communicate the fever. Dr. Lind mentions a fact, for which it is still more difficult to ac- count, that the same fever brought to this country in several American ships, attacked those only who had been on board the ships, others remaining uninfected, notwithstanding the freest in- tercourse with the sick on shore. * See the observations on the states of body wliich dispose to iafeo 4lon, towards the end of this section. 189 CONTINUED FEVERS. The stools, it has been observed, especially, if unusually fetid, are most apt to communicate the contagion to the air ; next to these, the patient's breath j and then the effluvia from his body. The last of the ways in which a contagious disease may spread, is by fomites, or matters impregnated with the contagion. Fo- mites often retain contagion for a great length of time, and may convey it to any distance. It is a general opinion, that a disease caught from fomites is more dangerous, than when received im- mediately from a person labouring under it. " It appears to me " probable," Dr. Cullen observes, " that contagions as they arise " from fomites are more powerful, than as thf y arise, immediate- " ly from the human body." In the observations of Sir John Pringle and others, we find striking instances of the virulence of infection from fomites. Fomites are not only said in general to communicate the disease in a worse form, but more readily also, than the sick themselves. Dr. Lind remarks, " I am convinced, " from very extensive experience, that the body of the sick is not " so apt to commmunicate the infection, as the dirty linen, 8cc. " which has been about him. The sick, Dr. Smith observes, and even the dissection of those who died, were not so apt to com- municate the disease, as substances which had been in contact with them.* Contagion adheres to the furniture and utensils employed about the sick, as well as to all kinds of clothes, woollen, cotton, linen, Sec. and even lurks in the walls of the apartments where the sick have lain. Woollen materials and wood are thought more apt, to retain contagion than most other substances. It is a curious and wholly unaccountable fact, relating to this paiit of the subject, that contagious diseases generally run a cer- tain course, notwithstanding all the means which can be employed to check their progress, and after this cease spontaneously, while the Avails of the houses, furniture, &c. must still be supposed to be highly impregnated with the contagion. This observation is made by Russel and others on the plague, and has been made, in- deed, on all contagious diseases. Those who have been bear the sick may infect others without having the disease themselves. Nay, those who have only been exposed to putrid effluvia may communicate typhus to others, while thejr-themselves escape.-f * It is even said, that contagion may be conveyed in the smoke arising from fomites while burning. Dr. Mead makes this observation with re- spect to the contagion both of small-pox and typhus. See Mead's Monha et Pracepta Medica. Tlie same observation is also made by Van Swieten and others. f " The most pernicious infection next to the plague," Lord Bacon ob- ser ves," is die smellof tiie jail, where theprisoners have been long, and close, " and nastily kept, whereof we had in our time experience, twice or thrice, CONTINUED FEVERS. 161 The greater the debility is, and the more strongly marked those symptoms are which have been called putrescent petechia;, fetor of the breath, and perspiration, &c. the more contagious in< gene- ral is typhus. This, however, is far from being an universal rule ; the milder forms of typhus are sometimes as contagious as the more malignant. The time during which the contagion is applied before it ex- cites the disease, is different in different cases. Sometimes its effects are almost immediate ; in general, however, the infected leave the place, where they receive the contagion, in good health, and feel no symptom of the complaint for one, two, three, or more days, and in some cases, though much more rarely, even for weeks after. It sometimes happens, that when those employed about pa- tients labouring under contagious diseases are suddenly taken ill, the illness proves to be different from that under which the sick labour. People have, for instance, on approaching those ill .ofthe small-pox, been suddenly attacked with sickness, head-ach, pain in various parts of the body, and other febrile symptoms, which with the help of proper remedies went off without shewing any of the symptoms peculiar to small-pox.* Dr. Chisholm ob- serves, that those exposed to the contagion of the fever of Gre- nada, were often immediately seized with nausea and slight ri- gours, which ahvays proved transitory, the fever not appearing till the 2d or 3d day, or perhaps not appearing at all.f It is not only true, that many exposed to the action of con- tagion escape infection, but it appears from a variety of obser- vations, that many escape infection who have actually receiv- ed the contagion of typhus into the system, or have it lurk- " when both the judges, who sat upon the jail, and numbers of tiiose who " attended the business, sickened upon it and died, therefore it Averegood "wisdom, that in such cases the jail were aired before they be brought " forth. It is probable," Sir John Pringle observes, after quoting this passage, " that one of the times hinted at, by this noble author, vvas at " the fatal assizes held in the year 1577, of which we have a more par- " ticular account in Stow's Chronicle, in these words. On the 4th, 5th, " and 6th days of July? were the assizes held at Oxon, where was aiv " raigned and condemned Rowland Jenkins for a seditious tongue, at " which time, there arose amidst the people sdfch a damp (an expression " in tiie.language of those clays signifying bad air) that almost all Avere " smothered, very few escaped that were not taken, here died in Oxon " 300 persons, and sickened there, but died in other places 200 and odd." * Cases of this kind are mentioned by Dr. Lind and others. X Similar to these observations are those of Sydenham and Rush, re- specting the measles. What Sydenham calls the morbillous fever, and Rush the internal measles, are complaints in certain respects resembling, in others differing from, measles; but which frequentiy attacked those, who were exposed to the contagion of measles. Rush also observes, that he frequently met wiih a slight feverish complaint, which those who for- merly had had the measles were subject to, on approaching patients la- bouring under this disease. }&2 CONTINUED FEVERS. ing about them for a considerable time, in such a manner, that it may be readily excited to action by slight causes. This obser- vation is sufficiently confirmed by Dr. Lind in his Treatise on Fevers and Infections. He found that those Avho had been but slightly exposed to the contagion often escaped the disease, if not soon after subjected to the action of debilitating causes ; and many recovering from contagious fevers, their bodies not yet being free from the contagion, had the fever renewed by such causes. Dr. Lind remarks, that he has often seen these observations con- firmed in sailors, after they had been for some time on shore* The fever, which at first seemed merely the effect of a debauch, or some other cause, soon assumed the precise form of that which raged in the ship they had left. In such cases we find contagion acting merely as the predisposing cause. These ob« eervations are farther illustrated by what is said by other authorsi particularly by what Dr. Rush says of his own situation while the yellow fever raged at Philadelphia. In speaking ofthe means of preventing the progress of conta* gious diseases, I shall have occasion to mention circumstanetil favourable to, or tending to prevent, their spreading, which to save needless repetition I omit at present; particularly those states of body which are favourable to, or tend to prevent, infection. It is a remarkable fact relating to this part of the subject, that although typhus, as has been observed, sometimes arises among brute animals, in the same way as among men, and is communis cated from one to another in the same manner, yet brutes cannot communicate the complaint to men, nor men to brutes ;* nor can one species of brute animal communicate it to another. Hogs, for instance, cannot communicate typhus to sheep, nor vice versa. It is remarkable that white people cannot communi- cate certain contagious fevers to blacks. And I have been in- formed by West Indians, that there are among the negroes many contagious febrile complaints, to which white people are not subject. I am now to consider the last and most important part of the subject, The Means of preventing the Generation, and checking the Pre gress, of Typhus. With regard to the means of preventing the generation of ty- phus, all that is necessary to be known was delivered in speaking * Illud prsterea notabile est (Waldschmidt observes) venenum pesti- lentiale, hominibus in&stum, non nocere brutis; et e contrario, brutorum pestem non nocere honiinibus. See Haller's Disput ad Morb. Hist, et Cur. pertinentes, vol. v. There are instances, hoAvever, of human con- tagion proving fatal to brute animals. Bocacce says, he saAv two hogs •eat some pieces of bread thrown from a poor man's house, who had died of the plague, in consequence of which they were seiaed with conyulsioos snd died in an hour. CONTINUED FEVERS. !**. eF the sources of typhus. If these are avoided, the generation of the complaint will be prevented. It will be necessary to speak at greater length of the means to be employed for check* ing its progress. On what has been said of the different ways in which conta- gious diseases spread, are founded many of the precautions em- ployed for checking their progress. . It is obvious that the first of these, actual contact with the sick, is to be avoided. The means suggested, by our knowledge of the air being a medium through which contagion spreads, are more various. As the contagious atmosphere extends only for a short distance round the patient, a principal means of avoiding infection is not to approach the sick. But as contagion is carried from place to place by the Avind, and as every place where the sick have been, even for a short time, may be supposed to be more or less im- pregnated with it, it must frequently happen, in close and crowd- ed parts of cities, when the number of sick is great, that the whole atmosphere will become more or less loaded with conta- gion. And it is difficult for those Ayho inhabit such places to escape infection. It is prudent, therefore, on the breaking out of pestilential distempers, to remove to the less populous parts of the city. Europeans residing at Aleppo, and other places fre- quently visited by the plague, choose the suburbs for their resi- dence. By this means, and by shutting themselves up in their houses, and avoiding all intercourse with their neighbours, while the distemper rages, they rarely suffer from it. Even the inha- bitants of colleges and monasteries in these countries, who live in a, great measure secluded from intercourse with their neigh- bours, frequently escape, while pestilential disorders rage. For those, however, who are obliged to remain in crowded parts of the city, where the deaths are numerous, it is proper to use some further precautions. When it is probable that the surround- ing atmosphere is more or Jess impregnated Avith contagion, the first thing that suggests itself is, that the way to exclude the con-? tagion is to exclude the external air. It is impossible, however, to do so entirely ; nor, if possible, could a house be long inhabit- ed Avithout afresh supply of air. The following observations de-. serve the attention of those, who may be placed in such circum* stances. Contagion sufficiently diffused becomes inert; were not this the case, the very purifying of goods impregnated with contagion, (which is generally done by exposing them to the itir) would be sufficient to spread the disorder on all sides. Whether it is owing to this circumstance, or the specific gravity of contagion, it is not easy to determine. But it has been observed, that those who reside jp the upper parts of houses often escape, Avhiie those'living on. the ground, floor are attacked with, pestiknliul levers. 184 CONTINUED FEVERS. The greater purity of the air at some distance above the surface of the earth, in places where such disorders rage, has been so thoroughly ascertained, in eastern countries, that those who shut up (as it is termed) during the plague, converse with their neigh- bours from high windows, or if those who live next them are also cut off from intercourse with the infected, the families meet on the house top without dreading the fever which rages below. Dr. Russel*Avas accustomed to prescribe for a crowd of patients in the plague who daily assembled under his window, and by whom the air to a certain height must have been strongly impregnated with contagion ; yet he neither received the disease himself, nor communicated it to those he lived with. It should be the endeavour, therefore, of those who live where the deaths are numerous, to be supplied with air from the tops of their houses. A very simple expedient is sufficient for this pur- pose, and will at the same time promote a free circulation of air in the house. If fires be kindled in several of the apartments, as the air of the house ascends through the heated chimnies, the doors ancl windows being kept close, the external air can enter on- ly by the chimnies which have not been heated. By similar means miners procure a current of fresh air, when they work at a considerable depth under ground. A free ventilation is generally kept up in the wards of hospi- tals, by kindling fires at the ends of the wards and throwing open the upper parts of the windows. It appears, however, that these means are less effectual than at first sight they appear to be. Maret observes, in the Memoires de Dijon for 1788, that in a ward, where the hospital fever raged, he found from several expe- riments, that the air towards the cieling, on a level with the open windows, was pure enough to preserve the life of birds ; while in the lower parts of the same wards, on a level with the patients beds, they sickened and died. The fact tends to confirm the ob- servations just made ; and shews the necessity of ventilating the wards of hospitals, where contagious fevers rage, by openings near the floor as well as the cieling ; and it is probable, that the former of these modes of ventilation will be found the most effec- tual. Such are the simplest means of checking the progress of con- tagious diseases, suggested by the knowledge of the air beings medium through which they spread. The same knoAvledge has suggested another set of means, those which seem to destroy, or correct the noxious properties of, the contagion, Avhiie suspended in the air. It is necessary, however, to premise that it is impossible in eve- ry instance to discover whether these means operate by destroying, or correcting the properties of the contagion ; or merely by for- * See RiiEid on the Plague. CONTINUED FEVERS. 185 tifying the body against its action. Many of them may be sup- posed to act in both ways. I shall arrange under the present head, those which may be supposed to act in the former Avay ; and under another division, print out the means which act evidently by fortifying the body aguinst the effects of the contagion. There can be no objection to this mode of arrangement, if the hint here suggested be kept in view. We may determine Avhelher any particular means possess the powti of destroying, or correcting the properties of, contagion, by observii g whether they are capable of purifying fomites. What means have, in this Avay, been proved to possess the power of de- stroying, or correcting the properties of, contagion, will be point- ed out in speaking of the purification of fomites. One of the most ancient means employed for destroying, or correcting the properties of, contagion suspended in the air, is caloric. It has been a firvourite opinion ever since the days of Hippocrates, that by exposing air impregnated with contagion to the action of fire, the contagion is as it were burned out.. And it Avill appear, when Ave consider the means employed for purify- ing fomites, that there is probably a great deal oi truth in this opinion. But how shall we apply the temperature sufficient for this purpose, which we shall find is very considerable, to the in- fected air ? Fires have frequently been made in the streets throughout a whole city, where the plague or other pestilential fevers raged. From this however we should not, a priori, ex- pect much benefit; and the fact is, that where it has been put in practice it has not proved successful, and seemed often prejudi- cial. In the year 1721, the plague raged at Toulon with such vif lence, that in the space of 10 months it destroyed about two thirds of its inhabitants. Many having insisted on fires being lv. 'o in different parts of the city, the public records Ave re con- sulted, and it Avas there found that on a similar occasion the same means had been tried without success. This, however, did not prevent the inhabitants from repeating the experiment. Wood was therefore Irid before every house, and at the sound of a bell all the fires were lighted, by which the city was involved in a thick smoke for nearly a Avhole day. The plague, hoAvever, suf- fered no abatement. The same measure was had recourse to both at Marseilles and London, when the plague raged in these cities, with no better success. It even appears, upon the whole, that large fires by heating the atmosphere prove hurtful; probably in consequence of the relaxation induced by the heat. Dr. Rush observes, that bakers, hatters, and blacksmiths, are more liable than others to contagious diseases. Thus it was perhaps that when fires had been kept burning for three days in London, while the plague raged there, on the night which succeeded these days no less than 4000 died, although not more than 12000 had bxen destroyed during the preceding three or four weeks. ™ Vol. I. ** Z 18d CONTINUED FEVERS. It appears, I think, upon the whole, that there are two ways fa which caloric proves useful in checking the progress of conta- gious diseases, the one by supporting a free circulation of air, in, the manner which has been pointed out; the other by destroying,, or correcting the properties of, contagion lurking in fomites. The manner in which caloric is employed for this purpose we- shall presently have occasion to consider. If fires do not produce one of these effects they seem to do little good, and if they over- heat the atmosphere they do harm. Some have supposed, that caloric is of service in contagious diseases, by drying the air, es- pecially in damp situations. It appears, from what has been said of damp air, that drying the air may be serviceable, by tending to prevent infection. There is a variety of substances which are supposed, while burning, to have a peculiar power of destroying, or correcting the properties of, contagion, independently of the evolution of caloric, which attends the use of them. Most of these, however, being employed for the purpose of purifying fomites as well as the contagious atmosphere, will be considered with more propri- ety under the next division. The firing of gunpowder, indeed, is chiefly employed with a view to purify the air, and is frequently used in hospitals, on shipboard,. Sec. How this acts has not been certainly ascertained; the agitation of the air, occasioned by the sudden explosion, must diffuse the contagion through a larger tract of air, and may thus render it innocent, or at least milder, and its properties, as some have sus- pected, may be corrected by the elastic fluid disengaged during the conflagration of gunpowder. It has long been thought, that the carbonic acid gas tends to correct the properties of contagion ; and the opinion seems to de- rive some support from its having been observed, that in south- ern climates pestilential fevers generally suffer a check during the vintage. This has been ascribed to the gas efolvedfrom the fermenting vats. Of whatever service this gas may be, there are many other circumstances during the vintage, which tend to moderate the violence, and check the progress, of contagious disorders: The fresh fruits, the approach of the cold season, and the general cheerfulness which autumn inspires. It would be worthwhile* however* since this gas may easily be procured, to determine, by more accurate observation, whether it tends to purify air impreg* nated with contagion. A variety of strong smelling substances seem to destroy, or> correct the properties of, contagion, without the assistance of fire. This quality is commonly ascribed to the odour of pitch and tar. When the plague raged in London, few of those em- ployed about the shipping, it is said, were seized with it. We are also informed, that those who work in storehouses of spiced CONTINUED FEVERS. 187 *rVe less liable to contagious disorders than others. One of the Tn03t celebrated of this class of substances is juniper.* There are Tione of them, however, on which much dependence can be placed. Camphire, so generally used as a preservative from infection, is ■supposed to act rather by fortifying against contagion, than by correcting its properties. A means belonging to this head, which is probably more effec- tual, is the steam of water, or, what seems to be better, of lime water, Avhich has been recommended for purifying the air in jails and hospitals.f Many have thought, that large tubs filled with cold water, and placed in the apartment ofthe sick, especially in summer, are serviceable-; and some recommend fresh willow and other boughs to be thrown into the water. The fumes of mineral acids have lately been proposed as a means of destroying, or correcting the properties of, contagion, and seem, from the experiments which have been made, to be very effectual.! We are now to consider the means of preventing infection through the medium of substances, which have been in contact with, or near, the sick, for fomites may receive the contagion from the air. It was once a custom to destroy the apparel, and other sub- stances, which had been in contact with the sick; and, if the dis- ease was of a highly contagious nature, even to pull down their houses. The total destruction of clothes, furniture, &c. however being expensive, various means have been proposed, and practised with success, to preserve the goods, and at the same time destroy the contagion which lurks in them. It is unnecessary to give a detail of all the means which have been employed with this view. It will be sufficient to point out those which have been found most successful. * " Juniper," Dr. Monro observes in a note to his Treatise on Inocu- lation, " being a plant unsuspected of having any thing poisonous in it, " there could be no harm in making some experiments with it, on ac- " count of the following facts communicated to me. A lady, when the " small-pox raged in her neighbourhood, bathed all her children daily in " a bath made with juniper, and burned juniper in their rooms. Not " one of eight or nine had tne small-pox. On telling this to a gentleman," Dr. Monro observes," he asked me, if this might not possibly be the rea- ** son why none of a parish, Avhere juniper grows in great quantity, were " infected by the plague, so destructive to Scotland, about the time ofthe " Restoration, while the neighbouring parishes suffered greatly, which he " assured me, he had been well informed was a fact." f See Considerations on Contagion in Maidstone Jail by Mr. Day; and Dr. Alderson'a Essay on Contagion. X See Dr. Carmichael Smith's Treatise on the Effect of the Nitrous Vapour in preventing and destroying Contagion, ascertained by a variety of trials, mailer chiefly by Surgeons of His Majesty's Navy, &c. See also the Report ofthe Council of Health on purifying the Air in the Military i&ospitals of the French Republic. !8S CONTINUED FEVERS. The most simple means of purifying houses and goods, is washing and exposing them to the air, and these means are very generally practised vvith success. It is common to wash, or Avhat is better "white-wash the Avails of houses, where the sick have lain ; and to procure a free circulation of air by opening the A\in- dows, and making fires in the house. The clothes, ancl other arti- cles which have been in contact with the sick, are washed and ex- posed to the ah for a considerable time. And in the different lazarettos of Europe, exposure to the air, for a certain length of time, is generally thought sufficient to purify merchandize, even from cities where the plague rages. Washing seems to be a less powerful means of purification than exposure to air; and those employed in washing fomites run the risque of infection. Dr. Lind particularly cautions aguinst washing clothes, impregnated with contagion, in warm water, as the steam is dangerous, unless they have been steeped for some time in cold water, or cold soap lees. The same author observes, that the air around fomites is sometimes so impregnated with contagion, that it is capable of communicating the disease. Fomites, highly impregnated, should be fumigated in the man- ner about to be pointed out, before they are exposed to the air, both on account of the circumstance just mentioned, and because the purification of substances highly impregnated with contagion, ought not to be trusted to exposure to air alone. This means is generally thought sufficient for the purification of fomites, vv hich have not been in contact with the sick, but received the contagion from a contagious atmosphere. The means most to be depended on is fumigation. This has been performed in various ways, and with a great variety of ma- terials. The most simple way is smoking with coals or wood; the lat- ter is preferred by Dr. Lind, and some think charcoal preferable to either. The articles to be purified being inclosed in a con- venient place, fires arc kindled, and the smoke and caloric confined, Avhich are thus applied to the fomites for a considerable time. If a house or ship is to be purified, the windows and other openings are closed, and fires kindled within. Much of the good effects of smoking in this way seems to de- pend on the temperature, which, it is said, should be but little inferior to that for baking bread. And this degree seems capa- ble of destroying contagion in every thing which can be exposed to its action for a sufficient length of time. But in order to make the purification as complete as possible, different articles have been added to the fire. The chief of tbese are yellow and white arsenic and sulphur. The last has been known i.s an antidote against infection since the infancy of me- dicine. In the same manner are used occasionally tar, pitch, •CONTINUED FEVERS. 159 i rosin, fi-mkincensc, camphire, cascarilla, various spices and aro- m-.i'.ics, jurnper, pine tops and shavings, turpentine, &c". It is often advise .b1" to purify a house or ship, when, from va- rious cin.ir.stances, the patients are prevented from leaving it. Wc must then .void the use of sulphur, arsenic, or other articles, whose fumes Avcuiti prove pernicious ; we must employ a less de- gree of temperature; and be cautious not to diminish too much the oxyger.es partcf the air; and in particular avoid the use of cbarro f. The ,;jrification, on these accounts, will be much less pcif'-ct than when the inhabitants can be removed, but it may still be serviceable. It is even found useful to burn cascarilla, and other aiomatics, at the patient's bedside. V\ hen the inhabitants can be removed, and the dwelling smo- ked as above pointed out, the contagion seems to be, in eArery inst-utce, wholly eradicated. Dr. Lind observes that he never knew .h, instai.ee in Avhich a ship, after being smoked, did not become t.. J'.ii i.ut only re tiers these about him more liable to infection, bin ii creases the virulence of his complaint. To this circum- stance Ave must in p..rt attribute the benefit derived from remov- ing those L.bcuiing under contagious diseases to fresh apartments. Wood and wooden materials, which, as has been obs:vv;>d, seem particulai ly apt to retain contagion, should be used by the sick as little ,s possible. The bedsteads in hospitals should be of iron ; and Howard advises the floors to be laid Avith bricks. Certain states of body have been observed to be more favour- able to infection than others. These, which to avoid repetition I omitted to point out in considering the ways in Aviiich typhus spreads, I am noAV to consider, together with the means of indu- cing the states of body which are unfavourable, and preventing or correcting those which are favourable, to infection. When the body is vigorous, and the mind undisturbed, we are least liable to infection. Whatever debilitates and relaxes is fa- vourable to infection. These observations,poin\: out most of the means to be employed, and most of the circumstances to be avoided, by those who are exposed to contagion. The most effectual means of preventing infectien is a :\v:-.c;\)iis, but temperate diet, ancl regular exercise. Wine has been long celebrated as a preservative when contagious fevers rage ; and it is, upon the whole, the best we are possessed of. TV is can only be said, however, of the moderate use cf wine. The body is at no rime more liable to infection than after intoxication. There is sufficient prcof of this in the observations of many of the authors J90 CONTINUED FEVERS. v-horh I have had occasion to mention. Those, Dr. Chisholre tobseives, who Avcre addicted to the abuse of intoxicating liquors, Were most, subject to the fever of Grenada. If, however, when the debility subsequent to a debauch in wine commences, it be driven off by again having recourse to wine, the tendency to in- fection is prevented. Thus it has frequently been observed, that habitual drunkards escape contagious diseases. Distilled spirits are more apt to be followed by debility, and strengthen the body less than wine. On these accounts they are a less poAverful preservative against infection. Opium and tobacco seem to act in the same way, but are inferi- 'ortowine. Tobacco,* whether used as snuff, smoked, or chew- ed, has long been a celebrated preservative against contagion. Chewing tobacco, in the presence of the sick, has the additional advantage of reminding Us not to swallow the saliva, which, in a contagious atmosphere, is believed to be dangerous. It would be difficult to prove, that any advantage is derived from an atten- tion to this circumstance ; yet as it is not improbable, from seve- ral facts which I shall presently have occasion to mention, that the first attack of contagion is sometimes on the stomach, and as sAvab lowing the saliva may be the means of conveying it thither, a pre- caution so easy should not be neglected. For similar reasons we are advised to stand with the back towards the patient. To this head belong those remedies which have been termed tonic. The Peruvian bark, when it neither oppresses the stom- ach nor otherwise deranges the system, may be ranked next to Wine, as a preservative against infection, and should be used along with it when the danger is great. Pure bitters are also used, but their effects are more doubtful. To these might be added, an endless variety of articles of less note, most of which do not de» serve to be mentioned. Vinegar is used in various ways 4 fre- quently washing the mouth and hands with vinegar, or dossils cf lint dipt in it, or in a mixture of vinegar ancl spirits of rosemary,- and put into the nostrils, are precautions little to be relied on. Some place confidence in chewing lemon peel ancl other aromat- ics. The opinion, that mercury tends to prevent infection, has in some places gained ground. Whatever be the truth of this opin- ian, quicksilver worn in a quill, Avhich is sometimes done even by medical men, can be regarded as nothing better than an amulet; a great variety Of these are in use among the vulgar in every Country.f We have reason to believe, from the observations of Dr. Cur- rie in a treatise which! shall have occasion to mention more par- * See Van Swieten's Comment, in Aph, Boerhaavii. | What truth there is in the observation, that those who have issues in anv part of the body are less subject to infection than others, it is ffciiiculty to say. See Dr. Smidi's Treatise en the Jail Fever cf Win.- "ihocter. CONTINUED FEVERS. IS4 llcularly in considering the treatment of fever, that the cold bath will be found abetter preventiAc against infection, than most of the means wich have been employed for this purpose. There is one poAVcrful means.of fortifying the body against in-j fection, which on many accounts deserves attention, namely, frequent exposure to contagion. It is well ascertained, that those who are frequently exposed to contagion become at length, in some measure, hardened sgainst its effects, just as those who are accustomed to drink much wine are less readily intoxicated by it, than others. Thus nurses and physicians often escape even tlie plague itself, although freely exposed to its contagion. Few things are better preservatives against infection than forti- tude and equanimity. Nothing we are informed, by those who voluntarily exposed themselves to the contagion of the most pes- tilential fevers was found an equal preservative against its effects with a steady adherence to what they believed their duty, banish- ing from their minds, as much as possible, all thoughts of danger, ancl avoiding every kind of passion, particularly the depressing passions. Everybody knows, hoAv much fear disposes to infec- tion ; on this account it is of consequence to strengthen the faith of the ignorant in the efficacy of any thing they believe capable- «f preserving against infection. Not only fear, and the other depressing passions, but every thing else that debilitates, disposes to infection. " The yellow « fever," Dr. Lining remarks, " Avas most fatal to those deprived " of fresh air, those from cold climates, those who had most " dread of it, those Avho overheated themselves by exercise in the *' sunshine, or by intoxicating liquors." And Dr. Chisholm observes, that convalescents, and those labouring under chronic disorders, were remarkably subject to the fevers of Grenada ; visiting the sick with an empty stomach, he adds, or when per- spiring was dangerous. In short, every cause of debility, whether of mind or body, predisposes to infection ; immoderate evacuations; the depressing passions, or the debilitating effects of the exciting i a poor ancl scanty diet, or excess in eating ancl drinking ; much heat, or a cold and damp air ; long continued vigilance, and even sleep, in which the circulation is more languid, than while we are awake, and which has been very generally observed to be favourable to the action of contagion. It is remarkable, that so slight a debilitating cause as a disa- greeable odour may have the same effect. Every kind of soap, Van Swieten observes, has a nauseous smell, but particularly the coarser kinds, which are made of impure alkaline matters and quick lime mixed with train oil. Diemerbroeck observes, that h\ his hospital, three women who had been washing linen were next morning seized. Avith the plague, and were all of them per* *uaded tiiey had taken it from the fetid smell ofthe soap. 192 CONTINUED FEVERS. In checking the progress of contagious diseases, it is of great importance, as much V.s possible, to sepaiate the sick from tlie healthy. No-more attendants should be employed than are, bb- solutely necessary ; and on the breaking out of a contagious fever a proper house should be prepared for the reception of the poor, Who arc attacked with the disease. The proper choice of nurses and ether attendants, is also a matter of consequence. As those employed about the sick arc unavoidably exposed to infection, it is of importance to choose such as are least liable to ic. The attendants on ihe sick in par* ticular should be made acquainted with the circumstances \a hich dispose to, or tend to prevent, infection ; and when, as frequently happens, there is any set of people in the place, Avho from having formerly had the disease, from having been frequently exposed* to ccivagicn, or from any other cause, are less liable to infec ion thaa others, they should be induced to undertake the office of attcri'—uits. All the exanthemata, and even the yellow fever of sultry clU males, are less apt to attack those who have formerly laboured under them. It was observed, that negroes are not subject to the yellow and some other fevers. This is true, however, only of those negroes who have come immediately from the coast of Af«« rica, or have been born and bred in the West Indies. It appears from the observations of Dr. Jackson, that negroes who have been in Europe, or the higher latitudes of America, are subject to the yellow fever. It was probably owing to this circumstance, that Dr. Rush hr.ving assured the black inhabitants of Philadelphia t;i;;t they were in no danger from the fever which lately ra<:ed there, many of them perished in consequence of attending the sick. It has been said, that people of different shades between white and black are as subject to the fevers of white people as these themselves are. Dr. Chisholm remarks, of the fever of Grena- da, however, that although people of all colours were subject-to it, mulattoes and mustccs were less subject to it than whiles, and negroes least of all. The habit of mind and body, as well as other circumstances which dispose to infection, have just been pointed out. Ao at- tention to these, it is evident, is proper in choosing attendants for the sick. People labouring under certain disorders are less liable to infection than others. It has been observed, for instance, that -scorbutic patients are less subject to typhus than people in health. But from the diseased we cannot choose attendants. While such as are least subject to infection, are chosen for attendants, care should be taken to prevent those from approach- ing the sick, who from any peculiarity in their situation are par- ticularly liable to it. CONTINUED FEVERS. 193 It is observed, in cities where pestilential distempers rage, that those lately from the country are particularly apt to be attacked by them, and that the fevers of warm climates are most apt to seize on those from cold latitudes. It often happens in the West India islands, that fevers are kept up for years, wholly in con- sequence of a constant supply of fresh troops from Europe. Dr. Jackson observes, that it is uncommon for people to have the yellow fever a second time, unless between the first ancl second attack they have been for some time in a cold climate. Such are the circumstances relating to the contagion of typhus, Which deserve attention. Concerning the manner in which this contagion acts, or on what parts of the system it makes its first attack, nothing satisfactory has been determined. It is a com- mon opinion, that it makes its first attack upon the stomach. This is far from being ascertained ; although some probable ar- guments may be adduced in support of the opinion. A disagree- able sensation in the stomach, and other disorders of this organ, are often the first symptoms of contagious fevers. Dr. Lind even observes, that an uneasy sensation in the stomach is some- times perceived the instant the patient is infected. " Many have " been sensible of a disagreeable sensation at the moment they « received the infection, and being questioned, said it was a dis- " agreeable smell reaching down to their stomach, not cadave- " rous, but like the smell of a neAvly opened grave." It is also in favour of this opinion, that dyspeptic affections often occasion irregular chills, resembling the cold stage of contagious fevers; and that fevers are sometimes cut short at their commencement, by the operation of an emetic ; and sometimes though more rarely, by diarrhoea. But when we reflect on tlie sympathy which subsists betAveen the stomach and other parts of the sys- tem, the inference from these facts is rendered very doubtful. It has been observed, that contagious fevers are particularly apt to derange any part of the system which has been debilitated, and consequently rendered more sensible to injury, by former disease or any other cause. From which it does not appear im- probable, that the superior sensibility of the stomach is the only cause of its being particularly affected at the commencement of fevers. It is remarkable that contagious diseases seem (to use the lan- guage of medical authors) to change others into their oavh nature ; so that while a contagious fever rages very generally, few other complaints make their appearance, and those which do, com- monly partake of the symptoms of the epidemic. The observa- tion has often been made of typhus, and still more frequently of the plague. This curious subject is considered at some length jh Dr. Rush's work on the Fever of Philadelphia^ Vol. I. Aa r&4 CONTINUED FEVERS. CHAP. III. Of the Proximate Cause of Fever. V^/f the various hypotheses which have prevailed respecting the proximate cause of fever, there are only two which at present deserve attention, that of Dr. Cullen and that of Dr. Brown. With the former it is necessary to be acquainted, because it i* blended Avith the writings of many of the best and latest medical authors; with the latter, both for this reason, and because in part it is founded on observation. Of Dr. Cullen's hypothesis it will only be necessary to give the reader a short account, that he may not find himself at a loss when he sees it alluded to ; Dr. Brown's It will be proper to consider at greater length. SECT. I. Of Cullen's Hypothesis. I cannot give a shorter account of this hypothesis than its au- thor gives in the 46th paragraph of his First Lines. " Upon the " whole," he observes, " our doctrine of fever is explicitly this: st The remote causes are certain sedative powers, applied to the " nervous system, which diminishing the energy of the brain, " thereby produce a debility in the whole of the functions, and " particularly in the action of the extreme vessels, Such how- " ever is, at the same time, the nature of the animal ceconomy, " that this debility proves an indirect stimulus to the sanguiferous " system ; whence by the intervention of the cold stage, and " spasm connected with it, the action of the heart and larger ar- " teries is increased, and continues so, till it has had the effect of " restoring the energy of the brain, of extending this energy to *the extreme vessels, of restoring therefore their action, and » thereby especially overcoming the spasm affecting them ; upon " the removing of which the excretion of sweat and other marks " of the relaxation of excretories, take place."' How the debility of the functions proves an indirect stimulus to the sanguiferous system ; Iioav this stimulus acts in exciting the cold stage and spasm ; how through the intervention of these the action of the heart and larger'arteries is increased; how the energy ofthe brain is restored, and Iioav this energy is extended to the extreme vessels;. Dr. Cullen attempts not to explain. Whatever rests oa these points, therefore, is confessedly hypo- thetical ; but if what rests on these is excluded from the accour.U of his hypothesis, what remains will be found nothing more than a short recapitulation of the symptoms of fever. It is to be re- membered, that a reference to the Vis Medicatrix Nalura in reasoning, respecting the proximate cause of diseases, always CONTINUED FEVERS. 195 amounts to a confession of ignoranee. See a more detailed ac- count of Dr. Cullen's hypothesis, from the 33d to the 46th para- graph of his First Lines. SECT. II. 'Of:the Brunonian Doctrine. OF the medical systems which have been proposed to the iworld, Brown's alone is in a great measure founded on obsen'a- tion. Many parts of it are simple deductions from facts, which must be admitted independently of all hypothesis. In a more advanced state of science, when the systems of Stahl, Hoffman, Boerhaave, and Cullen are forgotten, there will still remain enough of the Brunonian doctrines to preserve the memory of their au- thor. . Dr. Brown alone has made several steps towards a true system ■ of medicine. But in taking a few right steps, he has, (as indeed might have been expected from the state in which he found the subject) taken many wrong ones. It has proved unfortunate for ^medicine* that those who have attempted to construct systems have never been contented with advancing as far as they found themselves conducted by observation; but when this guide for- sook them, have groped their way without assistance, determined, whatever might be the faults of the system, to give it the appear- ance of a complete system. It is an attempt, worthy the pains it will cost, to separate the true from the false parts of the Brunonian doctrines ; to point out, ancl detach from the rest, what is really valuable in them'. This attempt I shall make in the present section, and in the next, endeavour to advance a feAv steps in addition to those which Dr. , Brown has taken, towards a, true system of medicine. The present section may be divided into two parts; the one, comprehending an account of the Brunonian system,; the other, the observations I shall make upon it. That power, by which the phenomena peculiar to the living state are produced, is termed, by Dr. Brown, excitability. Under this term he includes both the nervous and muscular power,* and seems in some places to suppose, that it includes a poAver differ- ent from either of these.! He considers every agent capable of pro- ducing any change on the living body, as an exciting power ;\ that * In the following notes the numbers refer to the paragraphs of Dr. Brown's Principia Mcdicinir;, and the Greek letters to the sections of the paragraphs. • For the sense in which Dr. Brown uses the term excitability, see,X, XI, Xll, XlV,&c. f See CLXVil. Jr. Sec XIX, &e. 196 CONTINUED FEVERS. is, a poWer dapable of exciting the action of the living solid.*. These powers he terms stimuli,* and their effect on the living solid he terms excitementf- The application of every agent to a living body, therefore produces excitement}, and in proportion as it has this effect, it exhausts the excitability ; that is, it renders the living body less capable of being excited by stimuli.^ Elf. Brown does not admit that there is any agent capable of producing a sedative effect; but maintains, that when the excitement, unless it is from an excess of stimuli, is diminished, (that is when the sedative effect takes place) it is always in consequence of the ab- straction of stimuli.*} The excitability produces no effect, and according to the, Brunonian system has no existence, except when acted upon by * Dr. Brown supposes the action of all stimuli the same, differing only in degree ; lie, hoAvever, divides them in different parts of his work, in three different ways, into universal and local; diffusible and natural or durable; and direct and indirect. " The effects common to all the exciting " powers are sense, motion, mental exertion, and passion. Now these " effects being the same, it must be granted, that the operation of all the " powers is the same." See XV. " Stimuli are either universal or local. " The universal stimuli are exciting powers, so acting upon the excitabili- " ty as always to produce some excitement over the whole system. The " appellation of universal is convenient, to distinguish them from the " focal. The local stimuli act only on the part to which they are applied, " and do not, without previously occasioning; seme change in it, affect the " rest of the body." See XVII, a, C, y. Dr. Brown uses the terms natural or durable stimuli, in contradistinction to diffusible, by which he means the stronger stimuli; such as distilled spirits, musk, vol. alkali, ether, opium, &c. See CIV, CV, CVI, CXXV1, CXXX, Q, and CCXC. "The stimulus of the articles of diet, not exclusive of the diffusible " stimuli, should be denominated direct, because it acts directly and iin- " mediately on the excitability of the part to which it is applied. Direct " stimulus, at least in so far as it regards the food, is assisted by another " stimulus, depending upon a distension of the muscular fibres, on which " account, for the sake of distinction, the latter should be cafled indirect. " The latter is owing to the bulk of animal and vegetable food; the " former is produced by a relation or affinity of the stimulus to the ex- " citability. The indirect acts upon the living solids, in so far as they are v to be considered as simple ; the direct acts upon them as livioe only." See CXXVII, see also CCLXV1II, &c. ^ t" The effect of the exciting powers, acting upon the excitability, may " be denominated excitement. ± See XIX, and a variety of other passages, in Brown's Elements of Medicine. § See XXIV, and a variety of other passages. «! *' The sedativ e affections as they are called, are only, a less degree " of the exciting ones; thus fear and grief are only diminudons or " lower degrees cf confidence and joy, not passions different in kind. " The subject of the passions admits of the same reasoning in every " respect as that of heat; and in the same manner all the bodies in na- " ture that seem to be sedatiAe are debilitating, that is, weakly stimyla- " ting, inducing debility by a degree of stimulus inferior to the proper "one." XXI, n. CONTINUED FEVERS. 19f •limuli.* By the total abstraction of stimuli it is as effectually destroyed, as by their excessive application,; it is on this account that Dr. Brown terms life a forced state. He does not consider the excitability as a property residing m and depending upon the mechanism of particular parts, but as an uniform, undivided property, pervading the whole system, which cannot be affected in any one without being affected in a similar way in every other part.f Upon the whole, according to the Brunonian system, the excitability (the power on Avhich the phenomena of life depend) is an uniform undivided property, residing in every living body whether animal or vegetable, to whose existence the constant application of stimuli is necessary, which excitement tends constantly to exhaust, which may be de- stroyed by the excessive application of stimuli, and which accu- mulates in consequence of their partial abstraction 4 With respect to the powers to which Ave are to attribute the accumulation of excitability, Dr. Brown leaves us wholly in the dark. The powers in question, it may be said, are those of di- gestion and assimilation. But how shall we reconcile this with a favourite hypothesis of Dr. Brown—That a certain quantity of excitability to last through life is bestowed on every living body * " If the property which distinguishes living from dead matter, or " the operation of either of the two sets of "powers," (that is, either the external agents, cr those which exist in tlie body itself) " be wilh- " drawn, fife ceases; nothing else than tlie presence of these is ne,- " cessary to life." XIII. ■J- •' Whether the excitement has been increased or diminished in a " particular part, and whether its diminution has been owing to direct or " indirect debility, and in either way the asthenic diathesis has been prc-r *' cluced, all the rest of the body soon follows the kind of change Avhich " has taken place, because the excitability is an uniform, undivided, uni- " versal property of the system." CLXVII. " And must Ave, givingup " our fundamental principle, after so compleat an establishment cf it, " allow that the excitability is not the same uniform, undivided property " over all the system," &c. CCXXXII. See also a note belonging to this paragraph. Dr. Brown hoAvever admits, that although the excitability is always affected in the same way in all parts of the system, yet it is affectea in a greater degree in that part on which the stimulus aqts than in any other. He maintained another opinion respecting the excitability, that a certain quantity is bestowed on every animal at its first existence, which determines the natural duration of its life. But this opink-n, .ibr reasons wluch will afterwards appear, I shall not at present lvtrno as terming any part of the Brunonian' system, with the other parts of which it is impossible to reconcile it. X See XVIII, XXIV, XXXIX. In one of these paragraphs he observe^. " this mutual relation obtains between the excitability and excitement, " that the more weakly the powers have acted, or the less the stiimiius "• has been applied, tlie more abundant the excitability beci-.iv.es. Tlie " more powerful the stimulus, the excitability becomes the more exhaust- • " ed." In XXXTX he observes, " in this case the excitabilhy becomes " abundant; because in ccnseOiUer.ee cf the stirnid: being withheld, it is " not exhausted," Sec, Sec what is sakl of sleep in CCXXX1X. 196 CONTINUED FEVERS. at its first existence ? This is a part pf the subject on which Dr. .Brown did not choose to enter.* Between the healthy state, in which the excitability and stimuli applied are in due proportion ; ancl death, in which the excitabil- ity is extinguished, either by an excess, or too great an abstrac- tion of stimuli ; the Brunonian system supposes all possible gra- dations. These are evidently to be divided into two classes ; those in which the excitability is to a certain degree exhausted by too great an application of stimuli; and those in which a morbid ac- cumulation is supposed to take place in consequence of too great •an abstraction of stimuli. In the latter of these, the body is said to be in a state of direct,t ancl in the former of indirect! debility. These are supposed-its morbid states. It is evident however, that there is a state of body different :from either of these, and different also from the healthy state. When stimuli are too much abstracted, debility is supposed im- mediately to insue ; but debility is not the immediate consequence ■of too great an application of stimuli ;the immediate consequent •of this is increased excitement. Dr. Brown therefore, although he maintains, that in the greater number of diseases the system is in a state of debility ;§ yet admits, that there are many, in which it is in a state of increased excitement.! The diseases of •excitement he terms Sthenic; those of debility, Asthenic. Which two classes include all general diseases. These principles Dr..Brown regarded as fully demonstrated;; •and with a want of caution altogether inexcusable, founded en •them his modes of practice. * See Dr. Beddoes's Observations ©n this part of the Brunonian system, in the introduction to his edition of Dr. Brown's Elements of Medicine. J " The debility arising.from defect of stimulus may be called direct because it is not produced by any positive noxious power, but by a sub- duction of the things necessary to support life." XLV. For an account ot this species ot debility, see various parts of the Principia Medians, particularly tlie XXXVlIIth and eight following paragraphs. ,.« V' The excitability thus exhausted by stimulus constitutes debility, which may be denominated indirect, because it does not arise from de- ^ feet but excess of stimulus." XXXV. For an account of this species of tS vv'vff.K VaVfty "f,Pas?aSes in the Principia Medicine, particularly tlie AAVlIth and ten following paragraphs. § See an account ofthe diseases of debility, from Dili to DCXCV .% See CCLI In CCCXXVHI, Dr. Brown observes, - to every s'tiies- ma, to all sthenic diseases, increased excitement over the whole svs- « lnD! 'sacom,J,0»c,/cumsta«ce; it appears during the predisposition, in ^ an mcrease of tiie functions of body and mind; and after the arrival cf disease, in an increase cf some ofthe functions, a disturbance of others, u and a dimmution of others, in such sort that the two latter phenomena are easily perceived to arise from the noxious powers that produce the .former, and to depend upon their cause." See an account oidisc?<*s ^of-excitementirom CCCXXVIII to (XC'UII * ('u,tR!*? CONTINUED FEVERS. m* /fs he allows excess of excitement to be a morbid condition of the body which we frequently meet with, he admits that an ab- straction of stimuli is in some cases requisite ;* but what he chiefly depends on for the cure of diseases is the addition of stimuli. On this, his plan of treatment in the diseases both of direct and indirect debility is founded. In the former, we are taught, that the morbid accumulation of excitability is to be re- duced by a cautious application of more stimuli.f In the other, in which the excitability has been morbidly diminished by too great an application of stimuli, the only mode of cure is, to begin by a stimulus but a little weaker than that which produced the dis- ease, and bring the system to the healthy state by gradually dimi- nishing the quantity of stimulus employed; giving time for the excitability to be sufficiently restored for the functions of the sys- tem to go on, in consequence of the application of the natural stimuli alone4 Such is the Brunonian system, or rather the system which may be collected from Dr. Brown's Elements of Medicine ; for as de- livered in that work, it is clogged with so many contradictions, that in order to give the reader a distinct view of the author's doctrines, I have been obliged to separate the system always* aimed at, and often clearly expressed in the writings of Dr. Brown, from many of his opinions, which have introduced much confu- sion into, and often directly contradict the fundamental principles. of, his system. It is oAving partly to this, and partly to Dr» Brown's never having given any concise view of his doctrines* but left the reader to collect them from his Elements of Medicine, that there are scarcely tAvo people, who, if questioned, Avoulck give the same account of them. Although the opinions here alluded to are not to be regarded: as any part ofthe Brunonian system, since they are incompatible- * See CVI, &c. and the mode of treatment in sthenic diseases from. CCCCLIII to Dill. t In DCLXXXVIII, Dr. Brown observes, " In direct debility, where " tlie redundancy of excitability dees not admit of much stimulus at a M time, ten or twelve drop's of laudanum every quarter of an hour, till the " patient, if, as is usually the case in such a high degree of debility, ha* *• wanted sleep long, fidls asleep. Afterwards when some vigour is pro-* " duced both by that and the medicine, and some of the excessive excita- " bility worn off, a double quantity of tlie diffusible stimulus should be ad- " ded, and in that Avay gradually increased, till the healthy state can " be supported by stimuli, less in degree, more in. number, and more " natural."' X In DCLXXXVII, Dr. Brown observes, 41 When indirect debility has " had mere concern in the case, as in agues or more continued fevers, oc— " casioned by drunkenness; and in the continent small-pox; the same " remedies are to be employed, but in an i.iverled proportion of dose. " Wc should consequently set out here in the cure with the largest doses, " such as are next in effect to. that degree of stimulus Avhich produced "the disease; then recourse should he "had to less stimuli, and a greater " number of them, till, as was said just now, the strength tan be supported '* by the acenstomary and lateral, v.inidi." 809 CONTINUED FEVERS. with it; it is necessary to say something of them, that my accoun* of this system may not appear defective. One ofthe most striking inconsistencies in the writings of Dr. BroAA-n is his supposition, that every living body at the com- mencement of its existence, receives a certain quantity of exci- tability, which if not extinguished by violent stimuli, or by too great an abstraction of stimuli, will last for a certain length of time. The quantity received (he supposes) determines the na- tural duration of life, it being impossible to protract it after that quantity is exhausted. " We know not," he observes, " what " excitability is, or in what manner it is affected by the exciting « powers. But Avhatever it be, whether a quality or a substance, " a certain portion is assigned to every being upon the com- « mencement of its living state. The quantity or energy is dif- " ferent, in different animals, and in the same animal at different " times. It is partly owing to the uncertain nature of the sub- " jeet, partly to the poverty of language, and partly to the no- " velty of this doctrine, that the phrases of the excitability being " abundant, increased, accumulated, superflous, weak, not vieVf u enough sustained, not well enough exercised, or deficient in " energy, when enough of stimulus has not been employed ; ti- " red, fatigued, worn out, languid, exhausted, or consumed, when " the stimulus has operated in a violent degree ; at other times " in vigour, or reduced to one half, when the stimulus has nei- " ther been applied in excess, or defect, will be employed in dif- " ferent parts of this work."* It is almost unnecessary to observe, that the different parts of the foregoing quotation are perfectly irreconcileable. The confu- sion, which Dr. Brown here attributes to the poverty of language and the novelty ofthe subject, arises from the most evident con- tradictions in his hypothesis. Dr. Beddoes justly observes, that " he who assumes that a certain portion of excitability is origi- " nally assigned to every living system, by his very assumption " denies its continual production, subsequent diffusion, and ex- " penditure, at a rate equal to the supply, or greater or less." An inconsistency in the Brunonian doctrines, if possible, stilt more remarkable than this, is the supposition, that both the above species of debility may exist in the same body at the same time. In CCXL, he observes, " as debility therefore, whether direct of " indirect, or both conjoined," 8cc. and after pointing out the doses of medicine suited to his two species of debility, he ob- serves, in DCXCI, " when the affection is more a mixture of " both sorts of debility, these proportions of the doses must be " blended together." If direct debility be that state in which the excitability is morbidly accumulated ; and indirect debility, that in which a morbid exhaustion of the excitability has taken place, in what state shall wc suppose the system to be, when both species of debility are conjoined ? For when the excitability and * See XVIII. CONTINUED FEVERS. 301 stimuli applied are in due proportion, according to the Brunonian hypothesis, it is in a state of health. Nay, in some places, he seems to maintain, that the same agent may at the same time induce both Species of debility. In CXXXVII he observes, " tho " same thing is to be said of excess in venery, which is partly an u indi; cct, partly a direct, always a great debilitating power." Is it possible to suppose that sleep should ever be the conse- quence of what Dr. Brown calls direct debility, of that state of the system in which every agent produces a greater degree of excitement than in the healthy state ? Yet in a variety of passages direct debility is regarded as capable of producing sleep.* Although he maintains, that the mode of action of every agent on the firing body is the same, (CCCXV, CCCXVI, CCCXVII, &c.) yet he is constantly obliged to admit, that there is a difference in the effects of different agents. (CCCI, CCC1X, &c.) To- wards the end of the latter of these paragraphs he observes, ' " when the excitability is worn out, by any one stimulus, any new " stimulus finds excitability and draAvs it forth, and thereby pro- " duces a farther variation of the effect." If the operation of all stimuli is the same, a new stimulus can produce no effect which may not be produced by changing the quantity of that first ap- plied. Are not the supposed states of direct and indirect debility op- posite conditions of body ? Can we suppose them to produce precisely the same train of symptoms ? Yet Dr. Brown is con- stantly forced into this inconsistency. (CLXI, CC, CCXXXIV, &c.) In CC he observes, " Epilepsy depends likeAvise on debi- " lity, and the same scantiness of fluids, only here the debility is " commonly of the direct kind. Fevers may arise from indirect " debility, as in the confluent small-pox, or where drunkenness " has been the principal exciting noxious power applied, but at " the same time the most frequent cause of fever is direct " debility." A variety of similar inconsistencies in the writings of Dr. Brown might be pointed out. In stating and commenting upon his system, Ave must regard the spirit of his writings, and over- look the passages wh.ich cannot be reconciled to the doctrines in geneAl maintained in them. When we consider the comprehensive nature and simplicity ofthe Brunonian system, and that many of the facts on which it * See CCL, &c If it be said, that the Brunonian system does not sup- pose that stimuli necessarily occasion a greater degiee of excitement when the system is in a state ot direct debility than in health, what shall we understand by the excitability being accumulated in the former case? Is there any other test ofthe excitability being accumulated but the greater degree of excitement pixxluced by the same stimuli? It is true, indeed. Dr. Brow*often loses sight of fiiis', one of the fundamental principles of his system. Vol. I. B b 202: CONTINUED FEVERS. rests are such as we every day experience in our own bodies, catr we be surprised that it laid hold of the minds of all who were not Wedded to former systems ? Dazzled by its lustre, it required some time for the observer to discover its defects. These, how- ever, are not less than its excellencies. I shall adopt the same mode of arrangement in the following observations on Dr. Brown's system, which has been followed in giving an account of it. All agents, according to the Brunonian system, are stimuli. Every thing, capable of producing any change in the living body, excites the action of the muscular or nervous system or both ; and in proportion as it produces excitement the excitability is diminished. According to this system then* there is no agent capable of diminishing tlie excitability without occasioning pre- vious excitement. Let us consider if this be a fact. It seems indeed to be a law of the living solid, that every agent applied to it in a certain degree, acts as a stimulus, that is, pro- duces more or less excitement; and if its action be on the ner- vous system, the subsequent exhaustion is always proportioned to that excitement.- Applied in other degrees, however, the same agent acts no longer as a stimulus. Distilled spirits re-- ceived into the stomach occasion excitement, and to a certain extent the greater the quantity the greater the excitement. But the immediate effect of a large quantity of distilled spirits sud- denly received into the stomach has often been instant death. Is this excitement ? The same is true of those agents whose first operation is on the mind. The passions within a certain degree of intensity act as stimuli, but beyond this they sometimes instantly extinguish life ; that is, destroy the excitability without previous excitement.' It is 'needless to multiply illustrations j every one's reflection will supply him with many. These agents act on the nervous j let us see how far the Bru- nonian doctrine applies to those whose action is confined to or chiefly exerted on the muscular system. A small quantity of opium applied to the heart occasions in- creased excitement. A large quantity does not excite in it vio- lent contractions, followed by the loss of excitability, but instant paralysis without any previous excitement. The first instance then, in which the Brunonian system departs from truth, is, in supposing that every thing, capable of acting on the living body, is a atimulus, and that there is no agent which directly destroys the excitability. It appears also, that excitement ma£ take place in the muscular fibre, without being followed by a corresponding exhaustion of CONTINUED FEVERS. „ 2.QS iits excitability; a circumstance of which Dr. Brown was not aware, and which strikes at the fundamental principles of his system. The influence discovered by Galvani, it is said, is so far from tending to exhaust, Avhiie it produces excitement, that it preserves the excitability of the muscular fibre in circumstances where it would otherwise have been lost. The excitability wc have seen according to the Brunonian doc- trine is an uniform, undivided property of the system, which can- not be increased or diminished in any one part, without being affected in the same way, although in a less degree, in every other. This is true of the excitability when the term is confined to that of the nervous system. As sensation and voluntary motion, in every part of the body, depend on the sensorium commune,; ancl the excitability of this organ may be diminished by stimuli applied to any part of the system, every part is affected in conse- quence ofthe excitement of any one. If Ave fatigue one.limb by violent exertions, we find that we have, though in a less degree,* diminished the poAver of every other. Dr. Brown laid hold of this and some analogous facts, and (as in many other instances) his excessive fondness for gene- ralisation made him overlook a distinction of great importance. The excitability of the nervous system may be said to be in- divisible, the nervous excitability every where depending on the state of one particular organ. But the muscular excitability ex- ists in every muscle independently of-its existence in any other. If we apply a strong solution of opium, for instance, to the ■denuded muscles of a limb, they are instantly deprived of their excitability. But the excitabifity of every other muscle of the body remains as entire as it was hefore the application of the opium. If an animal be killed by destroying the excitability of the heart, that of every other muscle remains after death, gra- dually becoming less in consequence of the powers of assimila- tion being suspended, t The excitability of the muscular and that of the nervous sys- .tem obey laws wholly different from each other; a circumstance which Dr. Brown either overlooked, or could not prevail on him- self so far to encroach on the simplicity of his system (which * The exercised limb is more debilitated than other parts of the body, because it not only suffers in common with these from the debilitated state induced on tiie sensorium, but the excitability of its muscles is also im- paired in consequence of the contractions excited in them. It is proved, m an experimental essay on opium, alluded to when speaking of the mo- dus operandi of this medicine, that contractions excited in the muscles of voluntary motion, through the medium of tiie nervous system, impair the ■excitability of the muscles in Avhich the contractions are excited without affecting that of any other. t Sec the experiments with opium aboA'e alluded ta 204 CONTINUED FEVERS. he considered its chief excellence) as to acknowledge. No man will make any considerable adv; ixement in science, whose mind is not prone to generalise, but of alLits propensities this requires to* be watched with most care ; it is that which is most apt to had to error. Dr. BroAvn seized on the great outlines of his subject with an impetuosity that would not permit him to examine its parts in detail. Another opinion, respecting the excitability which makes part of the Brunonian system,* is, that the constant application of stimuli is necessaiy to its preservation, ancl that life consequently may be regarded as a forced state ; an opinion Avhich seems also to have arisen from a general and very inaccurate view of the subject. Upon a cursory vieAv of the animal machine, the position ap- pears to be just. If we deprive the heart and arteries of their proper stimulus, (the blood) the excitability in every pnrt of the system is soon extinguished. That the excitability is extinguished in consequence of the abstraction of the stimulus, is the inference which Dr. Brown draws from this fact ; for I think it could easily be shewn, that it is this fact alone which he keeps in view, al- though he speaks as if his inference were drawn from a greet variety of observations, which however are not specified, Is there any other Way of explaining this fact? If there be, Dr. BroAvn's inference is rendered doubtful. If it can be shewn, that this explanation is not supported by a solitary fact only, but by a variety of facts, Avhich are inconsistent with the Brunonian opinion, it must then be admitted that Dr. Brown's inference it false. As there is a constant waste, there must be a constant supply ' of excitability. What the excitability is, and how it is supplied, have not been determined. We have reason perhaps to believe, that it is a property of the nervous matter and muscular fibre, depending on their mechanism; that the different degrees of exhaustion depend on this mechanism being more or less de- Tanged ; ancl that the supply is to be attributed to the restora- tion of the proper mechanism by the powers of assimilation. Whatever be said of the rest of these positions, this we are well assured of, that a constant supply of excitability is necessary ; and that this supply somehow or other depends on the powers of assimilation. It follows then, that these powers being destroyed, excitability must cease. When therefore we observe the ex- citability lost soon after the stimulus of the blood is withdrawn, we are not to infer that the presence of this stimulus is necessary • ■* I say, Avhich makes part of the Brunonian system, because I retard I the opinion ot a certain quantity cf excitability being bestowed on every living body ut the commencement of its existence, aiwFsorne other opin-' lens which have been mentioned, as making no part of that system OS- cause they are ^consistent with k. , i^ui.tm- CONTINUED FEVERS. 205 to the existence of excitability ; for we cannot deprive the'heart and arteries of the stimulus of the blood, without at the same time destroying the powers of assimilation on which the supply of excitability constantly depends. Dr. Brown's inference therefore is doubtful. But we may go a step farther. If this inference be just, the excitability must either be, as Dr. Brown supposes it, an uniform, undivided property of the system, so that wc may suppose iis ex- istence maintained in every part, by the action of stimuli on iinv one ; or every part of the system must be subjected to me un- interrupted application of stimuli. That the former of these positions is unfounded has just been sheAvn ; ancl the latter has not I believe been maintained. Stimu- li applied to any part of the living body produce excitement. Does excitement take place in the muscles of voluntary motion during sleep ? Yet their excitability remains. Dr. Brown's in- ference therefore is false.* We are now to consider the two great hinges on which the Brunonian system turns, the states of direct and indirect ticbhiiy. It Avas observed above, that between the healthy state, in which the excitability ancl stimuli applied are in due proportion ; and death, in which the excitability is extinguished, either by an ex- cess or too great an abstraction pf stimuli ; Dr. Brown supposes all possible gradations. These are to be divided into two classes ; those states of body in which the excitability is to a certain degree exhausted by too great an application of stimuli ; and those in which a morbid accumulation takes place in consequence of too great an abstraction of stimuli. The body in the latter of these classes is said to be in a state of direct, and ,in the former of indirect, debility. In the first place—of indirect debility. According to the Brunonian system a state of indirect debil- ity is that in which the excitability is more or less exhausted ; and consequently the same stimuli produce a less degree of ex- citement than in the healthy state. We need only reflect on what we haA'e a thousand times ob- served in our own bodies, to be convinced of the truth of the folloAving position ; that in proportion as we have been subjected to the action of stimuli, we become less capable of being excited by them ;° and if their application is continued, the strongest fail to rouse the system to any further exertion, till a state of * As the stimulus cf the blood is necessary to the existence cf the pow- ers of assimilation, and as the existence of excitability in eveiy part of the system depends on these powers, the constant stimulus of the blood is indirectly 'necessary to the existence of excitability. In this scr^c, but as far as 1 can judge in no other, can life be sakTm be a forced state. The loss of the excitability is not the immediate effect of the ;os^no tion mf the bkxxl, but of the t>u> pensicn of die powers of assimilation in consequence of its abstraction. 306 CONTINUED FEVERS. sleep (during which, if it be sound, there is the greatest abstrac- tion of stimuli which is consistent with health) has to a certain degree renewed its excitability. We read of men m long con- tinued sieges sleeping at the breech of a cannon. Ancl we know that the most violent tortures produce sleepHn the hardy savage, who can bear a. long application of such powerful stimuli without having life extinguished. The moderate application of the ordinary stimuli of life ren- ders sleep during a certain portion of the day necessary to our existence. We may delay sleep by constantly applying a stronger stimulus than that which preceded it ; but in proportion as it is thus delayed, it becomes the more irresistible, and the longer its continuance must be in order to restore the due degree of ex- citability. This part of the subject Dr. BroAvn has illustrated at length. His doctrine of indirect debility is, (with two exceptions after- wards to be pointed out) a fair deduction from a numerous train of facts, which he has arranged in a more systematic manner than any preceding author. The same observation will not apply to his doctrine of direct debility. This according to Dr. BroWn is a'state of debility, in -which the excitability is accumulated, and consequently every •stimulus produces a greater degree of excitement, than in that condition of the system which alone he allows to be the healthy estate. The first question which here presents itself is, what is that •condition of body which the Brunonian system admits to be the healthy state ? How shall we define that state in which it supposes the excitability and stimuli applied to be in due pro- .portion ? In the morning the quantity of excitability is proportiopably ■^reat, in the evening it is small, and between these there a)|e infinite gradations. Which of these states does Dr. Brown con- -sider that of perfect health ? From a review of his system it appears, tbat wherever there •is any addition made to the stimuli necessary for preservingthe body in a state of health, a morbid degree of excitement takes place, and a morbid exhaustion ofthe excitability follows.* How- ever trifling the degree of morbidity may be, according to the .Brunonian system it is a morbid state. According to this systepi then we are only in a state of perfect health on waking after a sound sleep. But what will support the doctrine of direct debility, if it * Admitting the Brunonian system, this is the only state cf health which •can be defined : When an addition is made to the stimuli necetsury fbr preserving the body in health according to this system, a condition of bo^y •differing only in degree from the most morbid, must be die consequence. CONTINUED- FEVERS. aor ean be shewn, that this is that state of the system in which stim- uli of every kind produce the greatest degree of excitement ; that in Avhich the excitability is accumulated in a greater degree than in any ether? If it can be shewn, that the definition which Dr. Brown gives of direct debility, applies, and applies only, to that state which, according to his system, is the only state of perfect health ? We come now to that part of the Brunonian system Ayherc truth for the first time wholly forsakes us. In other parts, if er- rors have appeared, they are the errors of rash induction ; that, we are about to consider, is, as far as I am capable of judging, al- together unfounded. I mean the application of the Brunonian doctrine of excitability to explain the phaenomena and treatment of general diseases ; which turns Avholly on the supposition, that in all diseases of the whole system, except those of increased excitement, (concerning the general nature of which there is no dispute) the body is in one of those states which Dr. Brown term* direct and indirect debility. Let us in the first place take a view of the diseases of direct debility. On revieAving all that Dr. Brown says of the hypothesis of di- rect debility, I can fiftdbutone fact on which it is founded ; and that a fact which, although at first a ievv it seems favourable to this doctrine, if fairly examined will not be found to afford any argument in support of it; namely, that the living body is strong- ly affected by the application of certain agents, food and caloric, when they have not for a considerable time been applied in the ttsual degree The mildest food will often destroy life in animals who have fasted for several days ; ancl a moderate temperature will produce violent effects on those who have been exposed to a great degree of cold. Of these states of body, supposing them in the extreme, it may be observed in the first place, that neither heat in the one case, nor food in the other, occasion excitement, which were the ex- citability accumulated, as the Brunonian system supposes, they ought to do. ' But admitting that the effects of these agents in such states of the body, are Avhat they ought to ber according to the doctrine of direct debility, they will go but a short way towards establish- ing this hypothesis. A state of direct debility is that, in which nil agents occasion a greater degree of excitement than in health. Do all agents produce a greater than ordinary excitement in an animal that has been exposed to hunger or cold ? Instead of ap- plying caloric to the animal that has been exposed to cold, and giv- ing food to that which has fasted ; to the former give food, and let caloric be applied to the latter. According to the Brunonian sys- tem violent excitement should still in both cases be the conse- quence. In both the excitability is supposed to be accumulated,. and to both according to this system powerful stimuli are applied. 208 CONTINUED FEVERS. But so much the reverse of this is the fact, that caloric in those who have fasted, and are still deprived of food ; and food in tboso who have been exposed to cold, and are still deprived of caloric, occasion a much less degree of excitement than in health. The truth is, that in animals under the operation of hunger or cold, ev- ery agent, except that Avhose application in tlie usual degree has been interrupted, produces less powerful effects than in ordinary states of the system. Ihe effects of every agent arc proportioned to the change it induces on the body. It is not difficult therefore to account for the effects of a temperature of 100°, being more remarkable in an animal which has been exposed to that of 10°, than in one that has been exposed to a temperature of 60° ; or for a hearty meal producing more powerful effects on him who has fasted for several days, than on one who has fasted for a few hours, al- though exposure both to hunger and cold tends to exhaust the ex- citability ; which Ave knoAV to be the case, from the effects of oth- er agents. It is a Avell known fact, that such a quantity of fer- mented liquor as proves a strong stimulus in the temperature of 50°, may be taken while the body is exposed to the temperature of IS" without producing any marks of excitement; yet in the latter case, according to the Brunonian system, an accumulation of excitability has taken place. According to this system, sensation is one of the effects of stim- uli. Are there any sensations more acute than the pains of hunger ancl cold ? The sensation of cold, it is true, is occasioned by the abstraction of caloric, that of hunger by the Avant of food ; but these sensations nevertheless are followed- by the same ex- haustion which succeeds powerful sensations from any other cause. The few facts on which the doctrine of direct debility is foun- ded, are referable to alaAv of the animal ceconomy, by which the body is rendered more sensible to the action of those agents whoso constant or frequent application is necessary to health, by their being for some time withdrawn or not applied in the usual degree* Exercise is another agent of this kind. A person who has long indulged in indolence is overcome by the slightest exertion ; but a high temperature or a full meal occasions no greater excitement in him than in those accustomed to exercise. We have instances of the same kind in the various natural agents which excite tlie different organs of sense—light, noise* sapid and odoriferous bodies. An animal which has lived longja the dark, is strongly affected by light ; one which has been long. accustomed to quietness, is disturbed by the least noise. The palate that has been habituated to insipid articles of diet, is strongly affected by animal food ; and he that is accustomed to a pure atmosphere, is sensible of odours, aa hich are not perceived by the inhabitants of alarge city. But in none of these instances CONTINUED FEVERS. 509 tol the body rendered more sensible to any other agent than that whose application in the usual degree has been interrupted. The doctrine of direct debility supposes that the abstraction of any one of these agents renders the system more st-^ sible to every agent, and that the effect of all is at all times excitement* The facts are, that the abstraction of anyone of these agents, only- renders the body more sensible to the action of that agent, and that the effect of that agent is not always excitement; but either excitement, or the reverse, according to the degree in which it is applied and the state of the body at the time, that is, according to the change it induces. If the change is moderate, it prov'os a stimulus, and within a certain range the greater the change is, the greater is the excite* rnent. Beyond this, it occasions debility, and when excessive, dea,th. Food in an animal that has fasted 12 or 14 hpurs, occa- sions excitement; and a full meal occasions a greater degree of excitement, than a scanty one. In an animal that has fasted three or four days, even a small quantity suddenly received into the stomach occasions debility ; a larger quantity, death. The same is true of every other agent, whether natural or arti- ficial, of every thing capable of producing any change on the liv- ing body. While the change induced is moderate, while it is consistent with the health of the parts, on which the agent acts, excitement is always the consequence ; but Avherever the change induced is sufficient to derange the mechanism of the living solid, (if I may use the expression) to induce a morbid state, its imme- diate effects are debility or death. It ceases to produce any de- gree of excitement. Thus, with regard to the diffusible, that is the artificial, stimuli, a small quantity of opium or tobacco, applied either to the nervous system or muscular fibre, occasions excite- ment ; and within a certain range, the more ive apply, the greater the excitement-; but beyond this, their effect is not excitement, but a direct diminution or destruction of the powers of life. These facts will be stated at greater length in the next section ; it is sufficient here to shew, that they are incompatible with the Brunonian doctrine of debility. The morbid states we have been considering, namely, those in which the animal body is exposed to the effects of cold and hunger, are the supposed states of direct deViiity, of Avhich Dr. Brown speaks with most precision. It is unnecessary to con- sider particularly any ofthe others, because one observation ap- plies to all of them ; there is none in which many agents do not produce as little or less excitement than in health; therefore there is none in which the excitability is accumulated. With regard to th6 diseases in which Dr. Brown supposes the system to be in a state of diminished excitability, a similar obser- vation applies to them ; there is no genera! disease in which the Vol. I. C c Sl» CONTINUED FEVERS. system is rendered less sensible to the action of all agents, fa typhus, it is less sensible to that of opium and wine ; but a degres of exercise or heat which would not incommode us in health, is in this complaint often capable of destroying life. Upon the Avhoie, the following, as far as I am capable of judg- ing, are the facts which Dr. Brown overlooked in framing his hypotheses of direct and indirect debility. Every agent is capable of producing either excitement, or de- bility, without previous excitement, (which may be termed atony*) according to the degree in which it is applied. In health, the degree in Avhich any agent produces moderate excitement,t and that in which it produces excessive excitement^ or atony, are in a certain ratio to each other; ancl this ratio is such, that the natural agents applied in the usual degree, viz. « certain temperature, a certain quantity of blood, a certain quan- tity of exercise, &c. always occasion moderate excitement, never excessive excitement or atony. In general diseases the laws of excitability are changed. The same degree of temperature, the same quantity of blood, the same quantity of exercise, Sec. either stimulate in excess, as in the dis- eases of excitement; or produce atony, as in those of debility. This change in the laAvs of excitability Dr. Brown overlooks, and constantly supposes them the same in health and disease, that is, he supposes the effect of agents in all cases either of health or disease to be excitement, ancl tins excitement always to be fol- lowed by exhaustion ; so that when he observes, that any agent in a diseased state of the system does not occasion so powerful an effect, or occasions a more powerful effect, than usual; he sup- poses the body to be rendered in the same degree more or less sensible to the action of all other agents; because in health kis found that when those parts of the system on which the animal functions depend become more or less sensible to the action of any one agent, they are at the same time rendered more or tess sensible to that of every other. The facts here alluded to will be considered at length in the next section. It must appear to every one who attentively considers the Bru- nonian system, that its author, in speaking of diseases, has con- stantly in view the healthy state of the animal body, and attempts in vain to apply to its morbid states those laws which by fair induc- tion he lias demonstrated regulate the excitability of certain nam ofthe system in health. For if we confine the application of the Brunonian theory to the organs on which the animal functions * See the definition of atony, in the next sect. (III.) t See the definition of moderate excitement, in the next sect (VIII), % See the definition of excessive excitement, in the next sect. (X) CONTINUED FEVERS. Sli depend* in a state of health, in which all agents are stimuli, (atony being ahvays a morbid state) and suppose the condition of these organs in the morning that of accumulated, and their con- dition in the evening that of exhausted excitability, Ave shall find this theory (Avith a few exceptions relating to the nature of exci- tability) equally simple and just. SECT. Ill.f Facts relating to the Laws ofthe Excitability ofthe Animal System in a State of Health and Disease. I. Excitability is that quality of the living solid which distin- guishes living from dead matter. In the title of this section I use the term living system, instead of living solid, because I do nqt speak of particular parts of a liv- ing system, but of the living system as a whole, capable of being generally affected by certain causes, which may therefore be termed general, in contradistinction to those whose action is con- fined to particular parts of the system, and which only affect the excitability of those parts. Dr. Brown, it has been observed, maintained, that there is no cause Avhich partially affects the excitability of a living system-; but facts have been adduced to prove this opinion erroneous ; of such causes hoAvever I am not to speak, but of those affecting the excitability more generally. How it happens that certain causes applied to a part affect the excitability of the whole, or a great part of the system, it is not necessary to enquire ; it is sufficient to be assured of the fact. I have already had occasion to remark, that this seems to depend on the nervous matter being diffused through every part of the system, and its state every where depending on that of one organ, the brain, which in its turn is affected by every cause acting on any part of the nervous matter. It is to be recollected then, that in the following observations an attempt is made to trace the laws of the general, not the local, affections of the system ; our knowledge of the latter being ex- tremely imperfect. Every occurrence in life is an experiment on the animal system as a .whole ; consequently on this part of the Subject our observations are as extensive as perhaps they ever * It will appear, as far as I can judge from what is said in tlie next section, that it is to these organs alone, that the Brunonian doctrine of ex- citability is at all applicable. X About six years ago, the rode outlines of the following section were read before the Royal Medical Society of Edinburgh, and iiioerted in the H'jvk.* of the Socictv. 213 CONTINUED FEVERS. can be. When an animal is exposed to the action of agents, exer- cise, food, caloric, See. it is easy to observe th-ir effects upon it as a whole ; but it would require a train of minute experiments and a far more extensive knowledge of the animal ceconomy than we possess, to determine the manner in which they act on each par- ticular part of the system. A full meal we know produces in a healthy animal general activity; but in the production of this effect, what part is to be attributed to the action of the food on the stomach and boAvels, what to the effects of the increased Aoav of chyle into the mass of blood, what to the change induced on the brain, what in short to that induced on the nervous or muscular mat- ter in each particular part of the system ? To trace the laws ofthe local affections of the system, we must make experiments for the purpose; and the results of the best conducted experiments of this kind must ever be fallacious till we know how far and in what manner one part of the system depends on another. If we wish for example to trace the laws ofthe muscular fibre exclusively of other parts of the system, on the very outset our progress is checked, by a doubt which the united labour of physiologists has not yet been able to solve-r-Do agents applied to the muscular fibre act directly on that fibre, or through the intervention of ner- vous matter ? I confine the following observations to the animal system, be- cause we are not possessed of a sufficient number of facts to trace the laws of the living vegetable system. II. Excitement is a state of activity. By excitement is not necessarily implied contraction ; because the term is not confined to the muscular system ; the nervous system may be excited without occasioning any contraction in the muscular. I do not adopt Dr. Brown's definition of excitement, that it is the effect of agents on the living solid ; because they of- ten produce a state very different from excitement. ' III. Atony is a state of inactivity, that is, of debility, in which ev- ery part of the system is pretematurally sensible to the action of some agents, and pretematurally insensible to that of others ; and watchfulness is the consequence. IV. Agent is any thing capable of occasioning a change in the stats of the living solid. In the Brunonian doctrine it is supposed, that every agent pro- duces excitement, that is, is a stimulus. The term agent isthere- fore rejected by Dr. BroAvn, and that of stimulus used in its stead. But it appears from the foregoing observations on that system, that the effects of agents on the living solid are either excitement or CONTINUED FEVERS. ?13 atony, according to the degree in which the agents are applied. When an agent occasions excitement, it is a stimulus ; when it occasions atony, it must have some other appellation expressive of this effect. V. Agents are cither Stimuli or Atonies. VI. Stimuli are those agents which produce excitement, (II.) VII. Excitement is either moderate or excessive. VIII. Moderate excitement is that which is followed by exhaustion. IX. Exhaustion is a state of inactivity, that is, of debility, in which those parts of the system, on which the animal functions depend, become uniformly less sensible to the action of ill agents ; ancl sleep, that is, a suspension of the animal functions, is the conse- quence. This state is ahvays the effect, and the degree of it is propor- tioned to that of the preceding excitement. This is the only state either healthy or morbid, to which Dr, Brown's definition of indirect debility will at all apply ; and litre it applies only to those organs on which the animal functions de- pend ; for those on which the vital and natural functions depend are never in a state of exhaustion. During sleep these organs suffer no diminution of vigour* but what is the consequence of the suspension of the animal func- tions. This;is another distinction of importance which Dr. Brown overlooks. The state of the heart and blood vessels after each systole is not that of exhaustion, as exhaustion is defined by Dr. Brown, nor does he indeed suppose it to be so. That it is not a state of ex- haustion might be demonstrated in various ways. It is sufficient however to observe, that the exhausted excitability can never be restored while the stimulus which exhausted it continues to act. A man will never recover from the fatigue of a long walk while he continues Avalking ; nor will the retina ever recover its sensi- bility while exposed to the same degree of light which impaired it. But the contractions of the heart continue to recur, although it is exposed to the uninterrupted action of the agent which ex- cites them ; for, as I have frequently observed in frogs, it a liga- ture be thrown round the aorta so that the heart continues untiorm- * Dr. Darwin even alleges that tlie vital functions are most vigorous during .sleep., su CONTINUED FEVERS. ly gorged with blood, its fibres are still alternately contracted and relaxed, and for the space of four or five minutes with the same frequency as before the ligature was applied. Thus, if we sprin- kle salt on a muscle, we do not produce permanent contraction followed by exhaustion, but alternate relaxations and contractions followed by exhaustion. But the state of the muscle in the re- laxation Avhich intervenes between the contractions, is essentially different from its condition in that relaxation which succeeds them, because in the former case the same agent, although its ap- plication has not been interrupted, is still capable of exciting the muscle to action.* The vital and natural functions are the powers of assimilation, by which the excitability of those parts of the system which suf- fer exhaustion is renewed. If these powers also suffer exhaust- ion, to what poAvers in the animal machine shall we attribute the reneAval of their excitability ? It is impossible that any exertion of these powers themselves can renew it j because every thing capable of exciting their action must increase the exhaustion, that is, still further diminish the excitability.! Besides, it is im- possible that the excitability of the parts on which the vital and natural functions depend, could be renewed while the same agents which occasion its exhaustion continue to be applied. If the or- gans on which the vital and natural functions depend Avere subject to the same exhaustion with those concerned in the animal func- tions, no animal could exist above a few hours. The excitability of the organs on which the animal functions depend, is renewed during sleep, because the stimuli which oc- casioned the exhaustion are withdrawn ; and the powers of assim- ilation, that is, the powers of life, remain. But if the natural stimuli occasioned exhaustion in the organs on which these poiv- ers depend, as the stimuli are never withdrawn, would not their uninterrupted application, a fortiori, prevent any renewal of the excitability, which they had been the only means of impairing.}: * See what is said of the nature of exhaustion in the last paragraph of this division. f It is this objection to the Brunonian system which forced its author in- to the supposition, that a quantity of excitability, which is to last through life, is bestowed on every animal at the commencement of its existence. In forming his system he could not but perceive, that admitting eveiy part of the body to be in a state of exhaustion, there is no power inherent in it capable of restoring its excitability. This formidable objection he found it necessary to get rid of, although at the expense of introducing into Ins system the most palpable inconsistencies. X There is one set of the organs indeed, on which the vital functions depend, which are subject to exhaustion, the intercostal muscles and dia- phragm. Thesearemusclesof voluntary motion; we can interrupt, re- new, increase, and diminish their action at pleasure, and like other mus- cles of voluntary motion they are subject to exhaustion. But the slight degree of exhaustion which takes place after each of tlie moderate ccn- iractkjis of these muscles in ordinar}'respiration, is sufficiently re§toreil CONTINUED FEVERS. sii In diseased states indeed the organs on which the vital and ftatural functions depend are often debilitated. But this debility we shall find to be of a nature so different from exhaustion, that excitement, instead of increasing, is the. only means of remo- ving it. By the addition of stimuli, we may rouse to action the organs on which the animal functions depend Avhiie they are in a state of exhaustion. A powerful affection of the mind, for example, will excite these organs while under the influence of fatigue, but it will leave them in a state of still greater exhaustion. What Dr. BroAvn says of the action of stimuli in removing this state is wholly unfounded ; the excitability of those parts of the system on Avliich the animal functions depend, the only parts subject to exhaustion, is most speedily and effectually restored during the total absence of every stimulus capable of affecting them. It may be assumed as an axiom, that that debility which can be re* moved by the operation of stimuli, is not exhaustion. X. Excessive excitement (VII.) is that which is followed by ato- ny. (III.) If we except cases of local disease, atony and its effects are the only species of debility to which those organs, on which the vital and natural functions depend, are subject. And to these, they are subject in common with the other living solids, those on which the animal functions depend. In exhaustion, (IX.) there is but one set of organs debilitated ; those concerned in the animal functions ; and these are rendered uniformly less sensible to the operation of all agents, till at length they cease to be excited, ancl sleep is the consequence. In atony (III.) every part of the system is debilitated, and be- comes pretematurally sensible to the action of some agents, namely, the natural agents, food, caloric, exercise, 8cc. (XI.) which in this state of the system, instead of acting as stimuli are atonies ; and pretematurally insensible to that of others, namely, those Avhich still act as stimuli, termed by Dr. Brown diffusible or artificial ; and watchfulness is the consequence. It must be recollected, that what is here said, is said of gencrah nninfluenced by local, affections. Local affections are so various and their nature so obscure, that it is impossible in the present state of our knowledge, to trace their laAvs. It wiil i.ppear, as far as I am capable of judging, from the following observations, tfi.it by the interval of rest which intervenes bctAveen these crntractions, during which the stimulus Avhich produced them is removed ; there is no mus- cle of the body which could not duri: & the whole life of tiie animal un- dergo such moderate contractions with the same inter ah I of rett, were there a stimulus fitted to excite them both in our sleeping and waking kduri, as in the cave of themu*ule» of inspiration* S16 CONTINUED FEVERS. it is owing to pathologists not having properly distinguished the local and general affections, that so much difficulty has occurred in tracing the laAvs of the latter, which seem to be very simple. XL. Atonies are those agents (V.) which produce atony. It has been observed, that every agent may produce cither ex- citement or atony, according to the degree in which it is applied. Atony is always produced by a greater degree, than that Avhich produces excitement. A certain quantity of those agents, whose first impression is on the body, such as opium, tobacco, &c. as Aveli as a certain degree of those agents whose first impression is on the mind, occasions excitement. (II.) A greater quantity both of the one and the other produces atony. (III.) The degree of excitement which any agent is capable of pro- ducing, is not in any particular ratio to the degree of atony Avhich a greater quantity of the same agent will produce. Thus, to- bacco will not occasion the same degree of excitement that opium or distilled spirits do ; but it is better fitted to produce atony. The exhibition of opium or distilled spirits will not be immediate- ly folloAved by atony, unless given in doses very great, compared with those which produce moderate excitement ; (VIII.) but a dose of tobacco, very little greater that which produces mode- rate excitement, -will produce atony. The same is true of those agents whose first impression is on the mind; grief, fear, hatred, disgust, are ill calculated to occa- sion excitement ; although when present only in a small degree, they have this effect ; but they are chiefly calculated to produce atony.* Love and joy, on the contrary, produce much excite- ment ; and only occasion atony when in excess. _ With respect to what Dr. Brown says of the depressing pas- sions, as it makes a part of his doctrine of direct debility, it must fall with that doctrine. Unless we alloAv that grief, fear, hatred, &c. occasion an accumulation of excitability, there is nothing which Dr. Brownt says on this subject that can be admitted. His assertion, that grief is only a less degree of joy, and fear nothing more than a diminution of confidence, is quite gratuitous. He might with equal reason assert, that confidence is a diminu- tion of fear, and joy a less degree of grief. The one set of pas- sions are as positive agents as the other ; and if the one tend more to excite, and the other to depress, it is only what is true of agents of every other species. A negative passion implies an * It is to be recollected, that Avhen these agents are present to such a degree as to occasion derangement of tlie bruin, the t;eneral laws of exci- tability no longer apply. . t Those under the operation of grief are rendered more sensible to joy ; thnse under the operation of fear, to confidence ; but they are ren- dered less sensible to the operation of every other agent. CONTINUED FEVERS. 217 absurdity. Every agent then is either a stimulus, or an atonic, according to the degree in which it is applied. It appears from what has been said, that atony is cither the immediate consequence ofthe action of atonies, that is, of agents applied in a greater degree than that Avhich produces excitement; or it is the consequence of excessive excitement. (X.) That exhaustion is never the immediate consequence of the action of agents applied in any degree ; but always the conse- quence of moderate excitement.* (VIII.) XII. The system in general is either in a state oi health or disease. Predisposition to general disease is a state that cannot be defined. There is perhaps no part of the writings of Dr. Brown more exceptionable than his observations on predisposition to disease. These however, as they do not properly form any part of his? system, it did not appear necessary to consider here. XIII. Health is either a state of moderate excitement, (VIII.) or ex- haustion. (IX.) That excitement which is followed by exhaustion is always healthy. The debility it occasions affects no parts of the system but those on Avhich the animal functions depend, and in them only occasions debility by diminishing their excitability; in conse- quence of which they cease for some time to be excited, and the animal functions are suspended, that is, sleep takes place ; during which the excitability of the organs concerned in these functions gradually increasing, they become sufficiently sensible to be again roused to action by the usual stimuli. The same stimuli agai:-. in a short time impair their excitability, which is again in like manner restored; hence the constant alternation of vigilance and sleep. During neither of these states are the powers of life at all impaired, the system is in as perfect health in a state of ex- haustion, as in that of moderate excitement. The powers by which the body is preserved do not partake of this alternation, it is confined to those powers, by which the animal is connected with the external world, by which he perceives and acts. The latter set of powers cannot exist independently ofthe for- mer, but the former may without the latter. We have reason to believe, that this is the case in the less perfect animals, which seem to possess no powers but those on which their existence de- ponds, and which may be regarded as the link that connects the marc perfect animal with the vegetable world. * When a state resembling exhaustion occurs without previous excite- ment, or when the exhaustion is not proportioned to the previous excite- rm "t, there is then present a morbid affection of the brain. Vol.. I. ' D d 2\* CONTINUED FEVERS. We have ample proof than even in the most perfect animals^ the vital and natural functions may be in a state of perfect vigour,- where the powers on which the animal functions depend never existed. Human and other foetuses have been born without the- head, in other respects well formed and ofthe full size. Such a foetus dies as soon as a ligature is thrown round the umbilical chord, because the blood no longer undergoes that change, which' is caused by the vicinity of the maternal blood in the^ placenta, and which is effected after birth by respiration ; a function which, depending on the nervous system, cannot be performed by an animal without the brain. Could such a fcetus after birth be made to respire, and supplied with nourishment, we have every reason to believe, from what wc knoAv of the animal ccconomy, that it would live and increase in size after birth as it does before it; but h would certainly experience no alternation corresponding to that of vigilance and sleep in the more perfect animal. The states then of moderate excitement and exhaustion, that is, of vigilance and sleep, are ecfually states of health. In both, the poAvcrs of life are unimpaired; and the greater the excite- ment is, provided it occasions no degree of atony, and the more complete the exhaustion which follows it, the more perfect is tho healthy state. We arc now to take a view of the statesof general disease. XIV. General disease is either a state of excessive excitement, (X.J or atony. (III.) That excitement only is morbid which is followed by atony. This degree is ahvays sufficient to derange some of the functions, and therefore properly termed excessive. Atony is a state of general debility, and is ahvays a morbid state. In health the powers on which the vital and natural functions de- pend are never debilitated. The circumstance which distinguishes a state of general disease from that of health, is a change in the laws of excitability. The natural agents no longer produce moderate excitement, followed by exhaustion, proportioned to that excitement; but either.excessive excitement or atony. The healthy alternation of vigilance and rieep therefore is disturbed, and uninterrupted watchfulness is the consequence. I must again observe, that I am speaking of general disease, strictly so called, that is, disease which neither is in any degree caused, nor infiucnccd, by any local affection. It is true, that sleep occurs in typhus, which is a general disease ; but it is either a morbid sleep, a degree of apo- plexy depending on a local affection of the brain, which is apt to supervene in this fever; or the sleep is natural, and then the de- gree of fever is slight, there not being present a sufficient degree of atony wholly to counteract the natural alternation of vigihncc CONTINUED FEVERS, 119 *ud sleep; thus it is, that in fevers natural sleep is almost ascer- tain indication of recovery. In a state of general disease, the artificial, or as they have been termed diffusible stimuli, produce either a greater or less degree of excitement than in health. In that state which is characterised by excessive excitement, the smallest quantity of opium or fer- mented liquors has violent efiects. In atony, large quantities of such stimuli are required to produce the degree of excitement consistent with health. XV. Atony is to be removed by inducing moderate excitement. As in atony all the natural agents, food, caloric, exercise, &c. arc atonies, Ave are obliged to have recourse to stimuli, Avhich in the healthy state occasion excessive excitement, but in the atonic are the only means by which we can induce moderate excite- ment. In proportion as we succeed in maintaining this degree of excitement, we relieve the morbid state ; and in proportion as this happens, the laws of excitability are changed to those which •prevail in health ; the natural stimuli begin to ^produce excite- ment, ancl we find it necessary to diminish the quantity of the artificial, till by degrees the healthy laAvs of excitability are re- stored, and tlie artificial stimuli laid aside. XVI. Excessive excitement is to be removed by changing excessive into moderate excitement. As excessive excitement in general disease is occasioned by the presence of the natural agents, the only means we have of dinii- • nishing the excitement are, diminishing the quantity of some of these, namely, of caloric, ofthe blood, and other fluids, and entirely preventing the application of others, food, noise, light, exercise, £cc. In atony where our object-is to increase excitement, we employ, stimuli; but in excessive excitement, where our object is to di- minish excitement, wc do not employ atohics, because the state which they induce is always a morbid one. XVII. General disease includes infinite varieties, from the greatest ex- cess of excitement, to the extreme of debility. BetAveen any two of these varieties however no other line of .distinction can be draAvn, but that which divides them into those in Avhich tlie excitement is above, and ll ci_e in wh'.ch it is below ihe healthy, that is, moderate excitement. (VIII.) XVIII. Siuplc fever is the only general disease, and may be defined, 22'J CONTINUED FEVERS. an excessive excitement or debility of all the functions, without any local affection. * When feA'er is in any degree occasioned by a local affection, such as inflammation, hemorrhagy, Sec. or has itself occasioned any local affection, it is no longer a simple fever. Then the ge- neral derangement is influenced by the local affection, the prece- ding observations will not apply to it, ancl the indications of cure in general diseases are not sufficient to restore the healthy state. It was sheAvn in the Introduction that we cannot give a defini- tion of fevers by any enumeration of their symptoms; for the cata- logue of symptoms will either be defective, and then will not apply to every case of fever; or too long to serve the purpose of a de- finition. The above definition is sufficiently concise, ancl it will be found to include every case of fever, at the same time exclu- ding every other disease. XIX. All other diseases are either local, or general and local. The only diseases which can be mistaken for simple general diseases, are affections of the heart and brain. A local affection of the brain is known by the presence of delirium, coma, or convul- sions ; a local affection ofthe heart, by the presence of palpitation or syncope. When these symptoms occur in fever, the case is complicated ; it is a case of general and local disease combined; and the preceding observations will not apply to it. XX. The laws of excitability are changed in fever. This change is suffic lent to account for the phenomena essential to fever, without supposing any change induced on the fluids. Wc know that the laAvs of excitability in fevers are different from those which prevail in health, because the same external agents, the same degree of exercise, the same degree of tempe- rature, the same quantity of food, of light, of sound, Ecc. which in health occasion moderate excitement, followed by exhaustion ; in fever produce excessive excitement or atony. The state of the living solids being thus changed, there must be a corres-> ponding change in the effects of the internal agents, the circula- ting and other fluids ; hence the phenomena of fever. XXI. The proximate cause of fever therefore is a change in the laws of excitability ; in consequence of which the same agents no lon- ger produce the same effects. How the remote causes of fever act in inducing this change, and on what change in the living solid this change in the laws of , * T\at lf' without any part of tlie system being more particularly af- fected than every other. ; CONTINUED FEVERS. 321 excitability depends, we neither can, nor ever shall perhaps be able to determine. This part of the subject is involved, in tho utmost obscurity. From the facts which have been stated, it is certain that the causes of fever do effect this change, and it is ev- ident that such a change in the "living solid must occasion the phe- nomena of fever. We could have told, a priori, that if the natural agents either stimulate in excess, or become atonies, the phenomena of fever would be the consequence. Some of these phamomena may be explained, by supposing that the principal natural agent, the blood, is so changed as-to pro- duce effects on the living solid, different from those consistent with health. There is a species of fever evidently produced by this cause. When opium or fermented liquors are received into the mass of blood, they so change the properties of this fluid, that it stimulates the heart ancl blood-vessels to more frequent and pow- erful contractions than usual. But if a quantity of these agents has not been received into the body sufficient to effect a chanro ill the laws of excitability, the other symptoms of fever do not appear ; ancl this always proves temporary, the exciubilhy of the heart ancl blood-vessels being affected by the blood in th'j usual way, as soon as this fluid has regained its usual properties, in consequence of the expulsion of the offending matter by the cXcretorics. It required but a very imperfect knowledge of the animal econ- omy to suggest that some of the phenomena of fever may be oc- casioned by the blood's acquiring morbid properties; and liil the time of Stahl, Hoffman, ancl Boerhaavc, physicians laboured in vain to shew that the blood is so changed in fevers as to account for all their phenomena, on the supposition ofthe solids remain- in."; in the same state as in health. The chimerical hvpothefis of Stahl was ill calculated to effect any favourable change on the sys- tems which preceded it. Hoffman was the first who pointed out the insufficiency of what has been termed the humoral pathology, ancl directed the attention of physicians to the solids. '• Porro " etiam omnes, que morbus gignunt, cause," he observes, in re- capitulating the outlines of his doctrine,* " operationcm suam " pollissimum perficiunt in partes motu et sensu prcsditas, et ca- " nalescx his coagmentatos, eoruin motum, et cum hoc fiuido- " rum cursum, peiwertendo ; ita tamen, ut sicuti varke indolis " sum, sic etiam varie in nerA'eas partes agunt, iisdemque noxam " affcrunt. Demum omnia quoque eximie virtutismedicamentu " non tarn in partes fluilas, earum crasin ac intempcriem corri- " gendo, quani potius in solidas et nervesas, earundem moius ai- " terando ac modcrando, tuam edunt operationcm : de quibus " tamen omnibus, in vulgari usque eo receptainorborum doctrina, " ahum est silcntium." * See tlie 3d vol.of tlie Mcdicina Ratioiialis Systematica of Huffman. 222 CONTINUED FFVERS. Boerhaave was sensible of the important change which the ob- servations of Hoffman had affected in medical systems ; but in modeling, he did not improve his doctrines. Boerhaavc attempted to explain the symptoms of diseases by attending almost solely to the state ofthe simple solid. His error was detected by suc- ceeding Avriters; and Dr. Cullen at length attempted a new sys- tem more nearly aliied to that of Hoffman, and pointed out the properties of the living solid, as those by which Ave are to explain the phenomena both of health and disease. But it was Dr. Brown who first taught the proper mode of investigating these prop- erties. In the foregoing observations, I have attempted to add some- thing to Avhat he has done, by which as far as I can judge the laAvs of excitability and in particular the state of the living solid in fevers are better ascertained. The folloAving observation how- ever must be kept in view ; the properties of the living solid can- not be altered without producing some corresponding change in the fluids, so that although it is certain that most diseases are the consequence of a change in the living solid, yet some of their phenomena must in a certain degree depend on changes induced on the fluids. XXII. In simple fever then there are only two indications of cure; the one to moderate excitement, the other to remove atony. (XV. XVI.) J K The means of fulfilling each of these indications have been pointed out in general. (XV. XVL) We are presently to con- sider them in detail. RE CAPITULATION. I. Excitability is that quality of the living solid which distinguish- es living from dead matter. II. • Excitement is a state of activity. III. Atony is*, state of inactivity, that is, of debility, in which eve- ry part of the system is pretematurally sensible to the action of some agents, and pretematurally insensible to that of others; and watchfufness is the consequence. IV. Agent is any thing capable of occasioning a change in the state of the living solid. V. Agents are either Stimuli or Atonies. CONTINUED FEVERS. S2> VI. Stimuli are those agents which produce excitement. VII. Excitement is either moderate or excessive. VIII. Moderate excitement is that which is followed by exhaustion. IX. Exhaustionis a state of inactivity, that is, of debility, in which those parts of the system, on which the animal functions depend, become uniformly less sensible to the action of all agents ; and sleep, that is, a suspension of the animal functions, is the con- sequence.* X. Excessive excitement (VII.) is that which is followed by atony, (III.) XI. Atonies are those agents (V.) which produce atony. XII. The system in general is either in a state of health or disease. Predisposition to general disease is a slate that cannot be defined. XIII. Health is either a state of moderate excitement, (VIII.) or ex1- haustion. (IX.) XIV. General disease is either a state of excessive excitement, (X.) or atony. (HI.) XV. Atony is to be removed by inducing moderate excitement. XVI. Excessive excitement is to be removed by changing excessive into moderate excitement. . XVII. General disease includes infinite varieties, from the greatest ex- cess of excitement, to the extreme of debility. XVIII. Simple fever is the only general disease, and may be defined ; Excessive excitement or debility of all the functions, without any- local affection. XIX. All other diseases are either local, or general and local. * The sleep which ibnot theeCict of, and proportioned to, the prece- ding excitement, is not natural, and is the contequence of a morbid ;if- fecuon of tiie brain, it is a local disease produced by compression, by va- riouj substances applied to the brain, such as opium, ub~<.co, &c 2-24 CONTINUED FEVERS. XX. The laws of excitability arc changed in fever. This change is sufficient to account for the phenomena essential to fever, without supposing any change induced on the fluids. XXL The proximate cause of fever therefore is a change inthelaAvs of excitability ; in consequence of which the same agents no longer produce the same effects. XXII. In simple fever then there are only two indications of cure { the one to moderate excitement, the other to remove atony. (XV. XVI.) CHAP. IV. Of the Treatment of Continued Fever. E may observe, in perusing the works of medical writers, that there are two general principles, on the one or other of which the treatment of fevers has been conducted. In speaking of the modus'opcrandi of the medicines employed during the paroxysm of an ague, it was observed, that such is the constitution of the animal system, that any extraneous body introduced into, ancl injuring any part of it, excites certain motions which tend to expel the offending cause ; and facts illustrating this observation were adduced. This property has been termed the Vis Medicatrix Natures. It has long been a favourite opinion among physicians, ancl perhaps it is a just one, that fever arises from this property, that it is an effort of the system to expel some offending cause or re- store the vigour of some debilitated part, that is, that the causes of fever in consequence ofthe peculiar mechanism ofthe animal machine excite motions calculated to expel them from the body, or repair the injury they have done. This opinion led physicians to mark with care the phenomena of fev er, whan left to run its natural course ; and in their plans of cure to attempt nothing more but to regulate and promote the sal- utary efforts of nature. Others observing, that fevers, left to run their natural course, often terminated Ltaliy ; and being aware, that the operations of nature are but ill understood, have constructed their plan of treat- ment on a different principle. Their attention has been directed to ascertain the symptcir.s which denote danger, and paving little attention to the operation of the Vis Medicatrix, they have cn- dec.vo.i.-cd to obviate these symptoms. w CONTINUED FEVERS, 225 Both modes of practice have occasionally been found suc- cessful ; and from both we are to extract what experience has proved to be valuable. In the one, our practice is whol- ly empirical. We observe, for instance, that spontaneous sweat- ing frequently attends the change from fever to health ; we therefore endeavour to induce this symptom ; but are wholly ig- norant ofthe manner in Avhich it acts in removing the disease. The other mode of practice is founded on our knowledge ofthe animal ceconomy. If, for instance, the action ofthe heart and arteries is so violent as to threaten danger, that knoAvledge teach- es us that their action may be moderated by diminishing the quantity ofthe stimulus which supports it. It is only in the latter mode of treatment therefore that we can properly lay down indica- tions. All that can be said ofthe former, is simply to relate what parts of it have proved serviceable. This I shall do before entering on what may be called the gen- eral plan of cure, in which our endeavours are directed to obviate the symptoms indicating danger, because confounding the other with this mode of treatment, which is better understood, tends to involve the whole in obscurity. When speaking of the crises of fevers, I had occasion to con- sider an opinion, very prevalent among those who attempt to pro- mote the operations of nature, that the peculiar symptoms term- ed critical, are ahvays the cause of the relief which attends their ap- pearance. From which they inferred, that a principal part of the treatment of fevers, consists in inducing these symptoms. Let us endeavour to determine to Avhat extent this inference is just. SECT. I. Of the Means of stopping a Fever at its Commencement, by indu- cing a Crisis. IT is only at the commencement of fever, we shall find, that we can attempt to induce a crisis, or at least that the attempt ever proves wholly successful. It was formerly observed, that it is only at an early period that spontaneous crises occur. A fever seldom terminates spontaneously by a crisis after the 10th or 12th day ; and a crisis is rarely induced by art after the 3d or 4th. The nearer to the commencement of the fever the at- tempt is made, the better is the chance of success. It appears from what was said ofthe crises of fever, that the symptoms most frequently critical are, the furfuraceous or lateri- tious sediments of the urine, sweat, vomiting, diarrhoea, hemorr- hagy, eruptions, swelling and suppuration of glandular ancl other parts, and cold chills followed by the other symptoms ofthe par- oxysm of an intermittent. We are now to enquire what advantage has arisen from inducing these symptoms by artx and what means are to be employed for this purpose. Voi. I. E e J25 CONTINUED FEVERS. We can only induce the critical sediments of the urine by re- moving the fever, or inducing sweat, so that of this symptom there is nothing to be said here. The propriety of inducing sweat, a point of much importance in the treatment of fevers, Dr. Cullen has considered at sonic length. I shall quote his observations, making the additional re- marks which the experience of others has supplied. " A third means, " he observes, " of determining to the sur- " face of the body, and taking off the spasm subsisting there, is " by the use of sudorific medicines and of sweating. " The propriety of this remedy has been much disputed, and " specious arguments may be adduced both for, and against the " practice. '• In favour of the practice it may be said, " 1. That in healthy persons, in every case of increased action " of the heart and arteries, a sweating takes place, and is seerniiiip " ly the means of preventing the bad effects, of such increased ac- " tion. " 2. That in fevers their most usual solution and termination " is by spontaneous SAveating. " 2. That even when excited by art, it has been found mini- «' festly useful at certain periods and in certain species of fever. " Upon the other hand, it may be urged against the practice of " SAveating, " \. That as in fevers a spontaneous sweating does not immc- " diately come on, so there must be in these some circumstances "different from those in the state of health, and which muy " therefore render it doubtful whether the sweating can be safely " excited by art. " 2. That in many cases the practice has been attended with " bad consequences. The means commonly employed have a " tendency to produce an inflammatory diathesis ; which if not " taken off by the sweat following their use, must be increased " Aviih much danger. Thus, sweating employed to prevent the " accessions of intermitting fevers, has often changed them into " a continued form, which is always dangerous. " 3. Tiie utility of the practice is farther doubtful, because " sweatin , when it happens, does not always give a final deter- " :':iinatn,.i, as must be manifest in the case of intermittents, as well " c.s in many continued fevers, which are sometimes at the bectin- '; ning attended with sAvcatin^s, which do not prove final, but on " the cc ntrary, whether spontaneous or excited by art, seem of- u ten to aggravate the disease. "■From these considerations, it is extremely doubtful, if tin CONTINUED FEVERS. J27 » K practice of sweating can be admitted very generally ; but at " the same time, it is also doubtful if the failure of the practice or " the mischiefs said to have arisen from it, have not been owing *' to the improper conduct ofthe practitioner. " With respect to this last, it is almost agreed among physi- " cians, " 1. That sweating has been generally hurtful when excited by u stimulant, heating, and inflammatory medicines. " 2. Thatit has been hurtful when excited by much external " heat, and continued with a great increase of the heat of the bo- « dy. " 3. That it is always hurtful when it does not soon relieve, but " rather increases the frequency and hardness of the pulse, the " anxiety and difficulty of breathing, the head-ach and delirium. " 4. Thatit is always hurtful if it be urged when the sweat is " not fluid, and when it is partial and on the superior parts of the " body only. " In these cases it is probable, that either an inflammatory dia- " thesis is produced, which increases the spasm on the extreme " vessels, or that from other causes the spasm is too much con- " firmed to yield easily to the increased action of the heart and ar- " tcries ; and upon either supposition it must be obvious, that ur- " ging the sweat, as ready to produce a hurtful determination to *' some of the internal parts, may'be attended with very great c!an- " ger. " Though the doubts stated above are to be attended to, and al- " though the practices above mentioned having been found hurt- *' ful are therefore to be rejected, it still remains true, " 1. That sweating has certainly been often useful in pre- " venting the accession of fevers when the times of this have been '* certainly foreseen, and a proper conduct employed. " 2. That even after fevers have in some measure come on, " sweating when properly employed, either at tlie very beginning u of the disease or during its approach and gradual formation, has " often prevented their further progress. " 3. That even after pyrexiae have continued for sonic time, " sweating has been successfully employed in curing them, as " particularly in the case of rheumatism. " 4. That certain fevers produced by a very powerful sedative " contagion, have been generally treated, so far as wc yet know, " most successfully by sweating." If avc compare the last observation with other parts ofthe quo- tation, a\c shall find that it is to be understood in a very lin.i.ed 12s CONTINUED FEVERS. sense. Where there is a tendency to a general sweat, which is accompanied with an abatement of the symptoms, it should be encouraged ; or even where no such tendency appears, if by the means about to be pointed out we succeed in bringing out a sweat which is thin and generally diffused, it seldom fails to bring relief. There are no other circumstances in which a sweat proves service- able in continued fever. If it be brought out by much warmth and heating medicines, or if it be partial and clammy, it will do no good. Even when spontaneous, profuse, and general, if not soon attended with an abatement of the symptoms, it will generally be found to have no other effect than that of reducing the patient's strength. When the sweat is partial and clammy, it is needless to encourage it. When it is profuse without bringing relief, we must always en- deavour to check it, by cautiously removing part of the bed clothes, cooling the air of the room, and allowing the patient to take cool drink; while at the same time we endeavour by proper medicines to remove the debility which is the cause of such SAveats. It is only in the more alarming forms of typhus that these sweats are apt to appear. Nothing is to be apprehended from checking them, but the worst consequences to be feared from their con- tinuance. It sometimes happens in this fever that very debilitating sweats occur, which yet relieve the febrile symptoms. In such cases we can only attempt to moderate the sweating, and obviate it3 hurtful effects, by employing the means which tend to restore the vigour of the system ; which will be considered at length in tlie general plan of treatment. " These instances," Dr. Cullen continues, " are in favour of " SAveating, but give no general rule, and it must be left to fur- " ther experience to determine how far any general rule can be " established in this matter. In the mean time, if the practice " of sweating is to be attempted, we can venture to lay down the " following rules for the conduct of it. " 1. That it should be excited without the use of stimulant, " inflammatory medicines. " 2. That it should be excited with as little external heat ancl " with as little increase of the heat of the body as possible. " 3. That when excited, it should be continued for a due length " of time, not less than twelve hours, and sometimes for twenty- " four or forty-eight hours ; always however providing that it pro- " ceeds Avithout the circumstances mentioned ;" that is, provided it relieves the symptoms, and is not partial and clammy. " 4. That for some part ofthe time, and as long as the person " can easily bear, it should be carried on without admitting of " sleep. CONTINUED FEVERS. 221 " 5. That it should be rendered universal over the whole body; " and therefore particularly that care be taken to bring the sAvcat- " ing to the lower extremities. " 6. That the practice should be rendered safer by moderate " purging excited at the same time." The propriety of this re- gulation seems very doubtful. It appears, from a A'aricty of ob- servations, that the only purpose for which we ought to move the body while we are endeavouring to promote sweat, is the regular expulsion of the faeces; and clysters in these cases are preferable to cathartics, because they are less apt to check the perspiration. " 7. That it should not be suddenly checked by cold any how ** applied to the body. " When attention is to be given to these rules, the SAveating " may be excited, 1. By warm bathing, or a fomentation of the " loAver extremities. 2. By frequent draughts of tepid liquors, K chiefly water rendered more grateful by the addition of a light " aromatic, or more powerful by that of a small quantity of Avine. " 3. By giving some doses of neutral salts ; most effectually and ** perhaps most safely by a large dose of an opiate, joined vriih a " portion of neutral salts, and of an emetic. " In what cases may cold water, thrown into the stomach in lt large quantities, be employed to excite sweating ? See Celsus, " lib. iii. chap. viii.—ix." These means it will be necessary to consider at greater length. The employment of wine and opium in fevers will be consi- dered in the general plan of treatment. Practitioners have now very generally abandoned the practice of giving wine with a view to promote sweat in fevers; and opium is rarely employed with this vieAV except in intermittents,* or in small doses to aid other medicines. Nauseating doses of emetics are more frequently employed for the purpose of promoting SAveat in continued fever. The follow-' ing are the circumstances to be attended to in their exhibition. 1. Both because a fever is seldom terminated critically after it has lasted for a considerable time ; and because nauseating doses of emetics are debilitating either by promoting sweatf or catharsis; they have been found most useful at an early period. 2. They may often be employed with advantage at later peri- ods if given a€out the commencement of the exacerbations, when these are distinctly marked. * See the treatment of an intermittent during the paroxysm, in book ;. of this voL t They are most apt to promots sweat when given with small doses of opium. When given alone however they generally have more or less cf this effect, which should be promoted by the use of mild lepid liquors. CSC CONTINUED FEVERS. 3. When much debility is expected, and they do not soon-re* lieve the symptoms, wc should not persevere in exhibiting them, Ipecacuanha and the preparations of antimony are the medi- cines usually employed. The latter are preferable, both because they more powerfully promote the action of the skin, and because small doses of ipecacuanha are more apt to excite vomiting. James's poAvder and tartar emetic are the preparations of anti- mony at present generally used in fevers. Most practitioners prefer James's powder. How far this preference is well founded it is difficult to say ; tartar emetic has the advantage of our being able with more certainty to regulate its dose. The poAver of neutral salts in promoting diaphoresis is seldom considerable, although almost all of them seem to possess this property in a greater or less degree. The salts composed of an acid and ammonia, particularly the saline mixture, prepared with ammonia and given in a state of effervescence, or the aqua um- moniae acetate, (the spiritus mindereri) seem to possess this pro- * perty in a greater degree than others. But the means of promoting diaphoresis in fevers whic,h chiefly demand attention, is the external and internal use of cold and warm water; which from the observations which have lately been made on it, promises to form an important part of the treatment in these diseases. The external and internal use of water, both cold and Avarm, is employed in fevers for other purposes besides that of promoting sweat. I shall therefore have occasion to mention it in other parts of the treatment. It will be the most distinct plan however to give at one vieAV the result of the observations Avhich have been made on it, ancl when I have occasion to mention it afterwards to refer to what I am to say here. I. Of the employment of cold water in fevers. Both the external and internal use of cold water in fevers Avas known to the ancients ; but among the moderns, it is only lately that the former has demanded much attention. Washing the bo- dy Avith cold water is said to have been first practised in fevers, In modern times, <.t BreslaAv in Silesia ;* and it appears that the practice was followed in some of the neighbouring countries. The external use of cold water in fevers however has never been prevalent in Europe, perhaps as Dr. Currie supposes from the manner in which it should be regulated not having been under- stood. Several late practitioners in sultry climates, particularly in the West Indies, have employed it freely ; and in 1786, Dr. Wni. * S:e a Dissertation entitled, Epidemia Verna qua Wratislaviara an- no 1757 afllixit, in Act. Nat. Curios, vol. X. CONTINUED FEVERS. S>3* Wright, who had practised for many years in the island of Ja- maica, gave an account of some cases of fever successfully treated by the affusion of cold water, in the London Medical Jour- nal. Dr. Wright has since published some additional observa- tions on the same subject, in a letter to Dr. Garthshore,in the 7th rol. of the Medical Facts and Observations, in which he gives an account of Dr. Gregory's manner of employing this remedy, and the success which attended its use in the Royal Infirmary of Ed- inburgh ; and in the 2d vol. of Annals of Medicine, he again gives a favourable testimony of its effects in the fevers of the West Indies. Dr. Jackson* ancl others also employed this reme- dy. Even the alternation of the Avarm bath and affusion of cold water has been practised in thess fevers, and it is said Avith the best effects. But no other writer has bestowed so much attention on the use of cold water in fevers, and so accurately observed its effects, as Dr. Currie of Liverpool, t 1. The manner of using cold water externally in fever. The most effectual way of employing cold Avater externally in fever is by affusion. The patient is stripped naked, and a bucket of cold water is'thrown over him. The temperature of the wa- ter should be from 40" to 6t" ; the quantity from three to five gallons. Dr. Wright used sea water ; Dr. Currie at first used fresh wa- ter, afterwards fresh water and vinegar, lastly a saturated solu- tion of common salt. " I was led," the latter author observes, " to prefer salt Avater to fresh on account of the stimulating effect " of sea salt on the vessels of the skin, by which I apprehend the ** debilitating action of cold is prevented. Salt water, cither for " the purpose of immersion or affusion, is more grateful to tho " patient than fresh ivater ; and it is Aveil known that it may be " applied to the surface for a length of time with much less hazard. * Persons immersed in sea water, and especially in saturated brine, " for some time together, preserve the lustre of the eye and the " ruddiness of the cheek longer than those in fresh water of an " equal temperature ; and such persons exhibit the vital reaction " stronger ivhen removed from it." Dr. Currie used a saturated brine in preference to vinegar and water, on account of the greater expense of the latter ; but thinks that vinegar and water of a proper strength will probably be found preferable to brine. He observes hcwever, that no bad consequences ensued from performing the affusion without the addition of cither salt or vinegar. 2. The period of tiie disease proper for the external use of cold. water. * See Dr. Jackson's Treatise on the Fevers of Jamaica. f ^ee Dr. Cm lie's Treatise entitled, Medical Reports on the effects- o£ water cold and warm as a remedy in fever and other diseai.es. 233 CONTINUED FEVERS. The proper period of the disease for the employment of the cold affusion is the commencement of the hot stage. It cannot be employed too early, provided the chills are over, and the hot stage completely formed. On the first or second day,* it often puts a stop to tire progress of the fever. It rarely has this effect when employed on the third or fourth day, and never at a later period. Still however, during the first eight or ten days, h U found to moderate the symptoms, and shorten the disease. Dr. Currie says he has seen it of service on the eleventh, twelfth, or thirteenth day. At an advanced period however, he observes, the water should not be more than fifteen or twenty degrees b&. low the heat of the body; and in most cases he thinks that after the ninth or tenth day, or earlier if the patient be much debilitated, washing the body with tepid vinegar and water ansAvers better than the cold affusion. He also observes, that injury is done by continuing the employment of the cold affusion during the period of convalescence ; an application of cold, safe in the violence of fever, often proving hurtful after the fever is removed. Dr. Currie frequently employed the cold affusion twice in the day, at noon ancl in' the evening. When it was only employed once in the day, the evening was found the. properest time. " The safest and most advantageous time," he observes, " for " using the aspersion or affusion of cold water, is when the ex- u acerbation is at its height, or immediately after its declination u is begun ; and this has led us almost always to direct it to ba " employed from six to nine o'clock in the evening." 3. The effects of the external use of cold Avater in fever. The immediate effects of the cold affusion are a diminution of the temperature and frequency of the pulse, which are soon fol- lowed by diaphoresis and sleep. In the following quotation Dr. Currie enumerates the cautions to be keptin view, in having recourse to this remedy, "1. If the aspersion of cold water," he obsenres, " on the " surface of the body be used during the cold stage ofthe parox- " ysm of fever, the respiration is nearly suspended ; the pulse * becomes fluttering, feeble, and of an incalculable frequency; " the surface and extremities become doubly cold and shrivelled, " and the patient seems to struggle with the pangs of instant dis- " solution. I have no doubt from what I have observed, that in " such circumstances the repeated affusion of a few buckets of *• cold Avater would extinguish life. This remedy therefore should " never be used when any considerable sense of chilliness is pre- " sent, even although the thermometer applied to the trunk of the " body should indicate a degree of heat greater than usual.*' In the 37th and 38th pages of his Treatise, Dr. Currie relates astri- * That i.«, if the cold chills have ceased, and the hot fit is completely formed at sjearly a period, CONTINUED FEVERS. 23* V.ing instance of the bad efiects of the cold affusion employed during the chills. " Neither ought it to be used when the heat measured by the " thermometer is less than, or even only equal to, the natural heat, " though the patient should feel no degree of chilliness. This is ** sometimes the case towards the last stages of fever, when the " powers of life are too weak to sustain so powerful a stimulus. " It is also necessary to abstain from the use of this remedy <; when the body is under profuse perspiration ; and this caution " is more important in proportion to the continuance of this per- " spiration. In the commencement of perspiration, especially " if it has been brought on by violent exercise, the affusion of " cold water on the naked body, or even immersion in the cold " bath, may he hazarded with little risk, and sometimes may be li resorted to with great benefit." The justness of this observa- tion is doubtful, at least not fully established. Dr. Currie relates a case (p. 40 and 41) in which the cold affusion was employed at the commencement of perspiration, and although the event pro- ved favourable, yet it suddenly produced a degree of cold in the extremities that was alarming, and had not the temperature at the time of affusion been very high, (106°) it is probable that it would have had worse effects. " After the perspiration has continued " for some time and flowed freely, especially if the body has re- *' mained at rest, either the affusion or immersion* is attended " with danger, even though the heat of the body at the moment « of using them be greater than natural. Perspiration is ahvays *' a cooling process in itself, but in bed it is often prolonged by u artificial means, and the body is prevented from cooling under ** it to the natural degree, by the load of heated clothes. " When the heat has been thus artificially kept up, a practitioner, -' judging by the information of his thermometer only, may be " led into error. In this situation however I have observed that " the heat sinks rapidly on the exposure of the surface of the body " even to the external air; and that the application of cold water " either by affusion or immersion is accompanied by a loss of heat " and a deficiency of reaction, which are altogether inconsistent ■" with safety." * * * " When employed in the advanced stages of fever, where the u heat is reduced and the debility great, some cordial should be " given immediately after it, and the best is warm wine." Almost all the trials which have been made with the cold affu- sion have been in contagious fevers,t that is, in those fevers in * The immersion is more troublesome and less beneficial than the affu- sion. The former was the manner in which the ancients used this reme- dy in fevers. j The cold affusion has also been employed in iuterautting fever; and Vofc. I. F f 334 CONTINUED FEVERS. which more or less of the synocha is succeeded by a greater de- gree of the typhus, which forms the chief part of the complaint. It is while the symptoms of synocha last hoAvever, as appears from the foregoing observations, that the cold affusion is most beneficial. How far it is proper in the fevers arising from cold, Sec in which the synocha prevails through the greater part of the complaint, stilL remains to be determined. Dr. Currie relates many striking proofs of the good effects of the cold affusion in contagious fevers; one of the most remark- ble is, that, of seventeen soldiers attacked with a fever of thij- kind, allof Avhom were immediately subjected to the cold affusion once or twice a day, in fifteen the fever was cut short, in two it went through its ordinary course. What Dr. Currie calls the cool affusion, is a milder form ofthe cold; the temperature of the water employed in the cool affusion is from 75c to 87°. This is recommended where from the de- bility of the patient, or continuance of the disease, the cold affu- sion is judged to be hazardous. Washing the body with cold water, or cold Avater and vinegar, is also a milder, though less effectual, way of using this remedy, and may be employed with advantage when the patient refuses to submit to the affusion. The same cautions however are still to be attended to, whether we recommend affusion, immersion, or sim- ply washing the body. When there is a sense of burning in the palms and soles of the feet, keeping them moistened with vinegar Is often very beneficial, and always safe and refreshing.* With respect to the internal use of cold water, Dr. Currie's conclusions correspond with those which have been made by oth- ers, and indeed by most practitioners in the course of their own practice. Cold water is not to be used as a drink in the cold stage. It increases the chills ancl other symptoms of this period. After the hot stage is completely formed, and especially when tiie heat is considerably above the healthy degree, there are few things either more grateful or more beneficial than large draughts of cold water- They produce the same effects as the cold affusion, but in a less degree, diminishing the heat and frequency of the pulse, and disposing to sensible perspiiation and sleep. After the SAveat has become general, cold water is inadmissible. " At this time," Dr. Currie observes, " I have perceived in more " than one instance, an inconsiderate draught of cold water pro- " duce a sudden chilliness both on the surface and at the stomach, from what is said in the 31st and following pages of Dr. Currie's Treatise, it is probable that it will be found an effectualmeans cf shortening the hot fit. On the effects of the cold affusion in intermittents, however, observa- tions are still Avanting. Dr. Currie also used die cold affusion with suc- cess as a means cf preventing the accession of the paroxysm, when the- strength was sufficient to bear this remedy in the absence of tiie fever. * See Dr. Currie's Treatise, p. 71, CONTINUED FEVERS. 233 ■«with great sense of debility and much oppression and irregula- " rity of respiration. At such times, on applying the thermome- « ter to the surface, the heat has been found suddenly and greatly " reduced. The proper remedy is to apply a bladder filled with ■« water heated from U0# to 120° to the scrobiculus cordis, and •*' to administer small and frequent doses of tincture of opium, as " recommended by Dr. Rush. By these means the heat is spee- " dily restored." Dr. Currie remarks however, that at the commencement of the sweat, before it flows freely and where the heat is considerable, a draught of cold water will often reduce the temperature to the degree at which perspiration Aoavs more freely, and thus bring the fever to a speedier issue. From the foregoing observations it appears, that the action of cold drink in fevers, is in every respect similar to, but less poAver- ful than, that of the cold affusion, and that the same cautions are necessary in the exhibition of both. II. Ofthe use of warm water in fevers. The tepid affusion is performed in the same way as the cold. There is no addition made to the water, and the proper tempera- ture is from 87° to 97°. When the water is applied by immer- sion it should be some degrees colder. It may appear at first view, that the tepid affusion would be a means of raising the temperature of the body ; that it should be employed where the cold affusion is improper; and avoided in cases where the latter is found beneficial. All this is contradicted hoAvever by the trials which have been made with it. " At first," the author just mentioned observes, " I imagined that the tepid " affusion might be beneficial in cases where the heat ofthe body '' is below the degree necessary to render the cold affusion safe. " I employed it therefore in those stages of fever where the heat " did not exceed the temperature of health. A little experience " however convinced me that this practice was not without hazard, " for I found that in many cases at least the heat of the human •*' body is lowered as speedily by the affusion of tepid water, as by " the affusion of water that is cold. If I mistake not, the heat is " lowered more speedily by the tepid water." It appears from Dr. Currie's observations, that the tepid affu- sion is beneficial in all those cases of fever, and in those only, in which the cold affusion has been found so ; but that the effects of the former arc much less permanent. He never saiv the tepid affusion stop the progress of fever. The effects of immersion in tepid water hoAvever do not corres- pond Avith tiiose ofthe tepid affusion. The tepid bath is ahvays improper where the temperature is considerable, and often so .viewable when it has fallen too low. 23G CONTINUED FEVERS. The same may be said ofthe internal use of warm water in fc ver. During the cold fit, or in a more advanced stage, when the tem- perature has fallen beloAv the healthy degree, warm drink is pro- per ; and where the temperature is not much above this degree, tepid drink assists the operation of other sudorifics. The drink .should also be tepid after the sweating has commenced, by Avhat- *ever means induced, except in those debilitating sAveats which occur in typhus, and reduce the strength without bringing relief, the means of checking which have been pointed out. With these exceptions, cold drink is more beneficial in fevers. It will be necessary aftenvards to make some additional obser- vations on the internal use of water as a means of diminishing excitement. Such are the means of promoting sweat in fevers,* and the cir- cumstances in which this ought to be attempted. The crises we are next to consider, are vomiting and diarhoca, concerning which a very few words will be sufficient. Spontaneous vomiting at an early period is often serviceable ; and excited by art on the first or second day it seems sometime^ to cut short the disease.f At a more advanced period however it is rarely beneficial, and when there is much debility always hurtful. * To these means may be added the use of mercury, which is very generally recommended by the practitioners of sultry climates, and whose good efiects seem in part, but not chiefly, to depend on its diapho- retic property. " By calomel," Dr. Wright observes, " the pores of the " skin A\ere opened, a resolution of the fever was brought about, and the " patient happily recovered." In another place he observes, " And Ave *l recollect no instarfce, where mercury had been freely given, and " persevered in till it shewed itself in die mouth, which was not attended " with the happiest consequence." Dr. Chisholm gave mercury to a very great extent, endeavouring as soon as possible to excite a salivation. He sometimes gave ten grains ev- ery three hours till this effect was produced, by which means he observes he has succeeded in cases which seemed desperate. ' It is probable however that these observations will net be found to apply to the:tevers of this country, lhave already had occasion to remark, that the fevers of sultry latitudes are generally accompanied with some local affection. For many of these, mercury is found a powerful remedy. Dr. Chisholm is one of the few practitioners who have given us any ac- count of the appearances on dissection after death in the levers of sultry latitudes. From his dissections it appears that, besides other local affec- tions, the liver, as indeed might be inferred from the symptoms of most ot the fevers ot the W est-Incues, was almost always diseased The ben- efit derived from mercury in affections of this organ has been well ascer- tained by the observations cf a variety of authors on the hepatitis Jt >s owing to tne local affections Avhich attend tiie fevers of sultry latitudes that their treatment is so difficult, and that that which succeeds in one eu- icicmic is ci.c;i hurtful in another. v f Sec Dr. Lind on Fevers and Infections. CONTINUED FEVERS. 237 Diarhcca we have seen sometimes proves critical in fevers ; it is a crisis however which we never attempt to induce. We often indeed excite a moderate catharsis with another vieAv, which will be pointed out in the general plan of treatment. We shall there also consider at length the cases of fever in which venesection ought to be employed. Venesection, that is, artificial hemorrhagy, seldom perhaps never proves a crisis in fe- ver. Its only effect appears to be that of diminishing excite- ment. It is therefore unnecessary to say any thing here of he- morrhagy. With respect to eruptions and glandular swellings, these are symptoms which we have it not in our poAver to induce. There is asuccedaneum for them however, if I maybe allowed the ex- pression, which is sometimes serviceable ; 1 mean blisters and rubefacients. The first observation to be made on the use of blisters is, that they are improper both in the well marked synocha, and in the worst forms of typhus. In the former their irritation increases the excitement ; in the latter, which is generally attended Avith a disposition to gangrene, they are often the means of inducing it.* The species of continued fever therefore in which blisters are chiefly employed is the typhus mitior, or what is commonly called the nervous fever. Ancl respecting the propriety of em- ploying them even in this fever, unattended by any local affection, there is much difference of opinion. No author has given so favourable a testimony of the effects of blisters in the typhus mitior as Dr. Lind. He recommends their application at an early period, and observes, that " In a " moderate infectious fever, where the source of infection is not " very violent, if twenty patients be blistered, sixteen will next " morning be entirely free from head-ach, heat, pain, ancl fe- " ver." Dr. Cullen was also a strong advocate for the use of blis- ters in fever ; but thought that they are employed with most ad- vantage at an advanced period of the disease. " It appears to " me that blistering may be employed at any period of continued " fever ; but that it will be of most advantage in the advanced " state of such fevers, when the reaction being weaker, all ambi- " guity from the stimulant power of blistering is removed." When Ave compare these with the observations of other au- thors, however, wc cannot help suspecting that both Dr. Cullen ancl Dr. Lind formed too favourable an opinion of this nmedy. " Whether exciting inflammation," says Dr. Fordyce, - has or " has not the same effect in a regular continued fever, which it * See the observations of Sir John Pringle, Mr. Clark, and others. A thick tough matter, like leather, covering blistered p. its, shews a ten- dency to gangrene. " If under this," Dr. Find observes, "whre er ruddy " specks impenr, it is a favourable .symptom; -i pa'.e cr dark, a very ** bad one. CONTINUED FEVERS. " has in health, can only be known by making these applications " to the body of a person affected with regular continued fever. •*' As far as the author's experience goes, when any stimulus hai " been employed so as to produce inflammation, when a patient " has become weak tOAvards the end of a regular continued fe- ■*' ver, the only difference which has occurred has been, that 'Sphlegmonous inflammation has not produced hardness, fulness, " and strength of the pulse ; but both phlegmonous inflamma- " tion and inflammation of the skin have occasioned greater fre- " quency of the pulse, have rendered it weaker and smaller, and " as in health have prevented sleep, ancl the patient taking the " same quantity of nourishment, and have depressed and deranged " the whole system."* Sir John Pringle observes, that blisters were only of service in the jail fever when the patient was threatened with an inflam- matory affection of the brain. " Blisters before useless became' " then of service."! He also remarks of the inflammatory fever, that at first he used to employ blisters at an advanced period of the disease, when he thought the patient could not bear any fur- ther loss of blood, but aftenvards confined their use to those case* Avhere the head-ach was considerable, which they seldom, failed to relieve. " NotAvithstanding my having watched the effects of blisters," Dr. Moorei observes, " with all the attention I am capable of, " and formerly Avith a strong prepossession in their favour, I can- " not assert that I ever knew vesications of any use in this dis- " ease," the typhus mitior, " but I have frequently seen the pa- " tient teazed by" their irritating quality without their seeming to " have any other effect." Upon the whole, although it is probable that the observations of Dr. Cullen and Dr. Lind are not wholly without foundation, those of the majority of writers tend toproi'e that little is to be expect- ed from blisters in fevers unaccompanied by local affections. For the removal of many of these, they are among the most power- ful remedies we possess. They are often employed with advan- tage in fevers for the removal of coma or delirium. When used with this vieAv, the head should be shaved, and'the blister applied over it. For like other local remedies, blisters are the more powerful in relieving local affections, the nearer they are applied to the part affected|| * Dr. Fordyce's third Dissertation on Fever. t Observations en the Diseases cf the A: my. .r Medical Sketches. H Blisters sometimes occasion a degiee of strangury from the absorption of the cantharides ; this effect may generally be prevented or removed by small doses of camphire or men. iy by dilution. Some anoint the part to be blistered by camphorated oil. It is difficult to say, whether the ►small quantity of can:phire which may be absorbtcj in this way is of ary service. CONTINUED FEVERS. 2S? With respect to rubefacients, they are still more improper than blisters in the synocha, because they occasion an equal or greater degree of irritation, and are unattended by any discharge.. In the worst forms of typhus indeed they are safer than blisters ; even rubefacients however may be the means of inducing gan- grene, where there is much tendency to it, and it does not ap- pear, that in any kind of typhus, unattended by local affections, rubefacients have been found serviceable. Mustard poultices ap- plied to the feet are often employed with advantage when coma supervenes on the typhus mitior.* Such are the circumstances respecting the artificial inflamma- tion of the skin in fevers which deserve attention ; a practice probably suggested by the relief which sometimes attends spon- taneous eruptions in these complaints. With regard to the last symptom mentioned among the crises ef fevers, shivering followed by the other symptoms ofthe parox- ysm of an intermittent, as we have no means capable of inducing it, there is nothing to be said of it here. SECT. II. Ofthe Treatment of Continued Fever token tee fail to induce a Criu's at its Commencement^ When we fail to induce a crisis at the commencement of con- tinued fever by some of the means which have been pointed out, which very frequently happens, we are then from our knowledge of the animal oeconomy, assisted by the experience we have had of the effects of a variety of remedies which have been employed in fever, to endeavour to moderate or remove the symptoms Avhich. indicate danger ; nor is this part of the treatment to be neglected while Ave are attempting to induce a crisis, if such symptoms shew themselves, which they seldom do at the commencement of the fevers of this country. For conducting this, the most important part of the treatment * It is the custom m such cases to apply rubefacients to the feet This practice originated from the doctrine of derivation ; according to which a congestion of blood in any part of the system is best relieved by occasion- ing a determination of blood to the part most distant from that affected; We have every reason to believe, that in the case mentioned in the text, rubefacients like other local means Avould be found most useful applied to the head, that is, as near the part affected as possible. The same pre- judice once influenced the employment of blood-letting, and it was the practice in affections of the head to let blood from the feet. f With respect to the uuxlus operandi of the medicines employed i» continued fevers, I shall as we proceed, in considering the treatment of these complaints, make such observations as the state of our knoAvledge pc-mits, m addition to what was said on this part of the subject when speaking of intermittents. It is unnecessary to make a separate section fcr tiie few observations Avhich remain to be made on this head. 946 CONTINUED FEVERS. of continued fever, there are tAvo indications, which were pointed out in the last chapter, namely, 1. In the synocha, to change excessive into moderate excite- ment. 2. In the typhus, to change atony into moderate excitement. The first of these indications is answered by avoiding the appli- cation of some of the natural agents, and diminishing the quantity applied, or stimulating power of others. The second is ansAvered, 1. By removing as far as can be done with safety, the natural agents which now act as atonies. 2. By applying those agents which still act as stimuli. I. Ofthe Treatment of Synocha. The indication of cure in synocha, it has just been observed, it to change the state of excessive into that of moderate excitement; which is effected by avoiding the application of some of the natu- ral agents, and diminishing the quantity applied, or stimulating power of others. Such is the simple oulliiie of the treatment in synocha, and the principle on which our practice in all idiopathic fevers, where the symptoms of synocha prevail, is conducted. The natural agents which are to be wholly removed in exqui- sitcly formed synocha, and the total removal of which is more or less necessary according as the symptoms are more or less vio- lent, are, 1. All exercise either of body or mind. 2. Every thing which makes an impression on the external senses. 3. All kinds of aliment, and the presence of feculent or other matter in the alimentary canal. 1. Every kind of motion is to be avoided, and that posture pre- ferred which requires least exertion ofthe muscles, the horizontal. The bed should be soft, that the patient may be as little as possible oppressed with his own weight, and the covering should be light. Speaking, Dr. Cullen justly observes, as it accelerates the respi- ration, is particularly to be refrained from. With respect to the mind, whatever excites the attention, Avhether business or amusement, is hurtful ; ancl whatever ex- cites the passions, still more so. Every cause of anxiety must be carefully avoided. There are no causes of anxiety more fre- quent in fever than thirst and a noxious atmosphere. The former is to be removed by permitting the patient to drink as freely as he pleases. CONTINUED FEVERS. 241 A noxious atmosphere is to be avoided by proper ventilation, hy permitting only one attendant to remain in the patient's room, by the speedy removal of all excremental matters; and as it is necessary that the patient should not only respire a pure air, but that his body should not be long immersed in its OAvn effluvia,* he should have frequent changes of linen, than which there is no- thing more refreshing to febrile patients. The linen should not be warmed ; it is sufficient that it is dry. In all kinds of fever, except where the temperature is below the healthy degree, the cooler it is the better. Even while the symptoms of synocha remain distinctly marked, if the disease has arisen from conta- gion, the body of the patient is found to generate it. In such cases therefore, to the foregoing means of preserving the purity of the air, should be added occasionally some of those for destroying or correcting the properties of contagion, pointed out when speaking of the causes of continued fever. When synocha arises from cold, or the other causes which more particularly be- long to this fever, this set of means are unnecessary till the symp- toms of typhus shew themselves. 2. All impressions on the external senses are prejudicial. The patient must be kept quiet, and the light excluded, which is the more necessary as the eyes are generally inflamed when the symptoms of synocha run high. " With respect to avoiding im- " pressions of all kinds," Dr. Cullen observes, " an exception is " to be made in the case of a delirium coming on, when the pre- " senting of accustomed objects may have the effect of interrupt- " ing and diverting the irregular train of ideas then arising in the " mind." This observation however is less applicable to synocha than typhus, both because delirium is a less frequent symptom in synocha, ancl because .when the symptoms run high in synocha, the only case in which delirium is apt to supervene, impressions made on the external senses arc most hurtful, end in this fever indeed seem often to induce the delirium. 3. With respect to the agents whose immediate action is on the stomach and intestines, food of every kind is hurtful while the symptoms of synocha run high. But after we have succeed- ed in moderating the excitement, the patient should be induced to take some of the lighter kinds of aliment; for in the treatment of synocha we must keep in vieAV the state of debility which con- stantly succeeds. With respect to the drink in synocha, every thing stimulating should be avoided. The best drink in this fever is water, ofthe use of which I have already bad occasion to speak. The diet in continued fever will be considered more particularly Avhen speaking of typhus. It is in that fever that it demands most attention. * There is reason to believe, that the application of fresh air to tlie surface is also useful in another way; it has been fiaud, that the air is viiiated by the skin in the same manner aa by the lun^s, although k^B rapidly. Vol. I. G g 342 CONTINUED FEVERS. While the symptoms of synocha are considerable, we must no? only avoid the introduction of aliment, but be careful to free the primae vis both of that and any feculent matter which they hap- pen to contain. It has already been observed, that an emetic is often serviceable at the commencement of all kinds of fever. This ought to be followed by a cathartic,* which, when the syno- cha is well marked, should be repeated till we are assured that the primie vix are cleared. It is also proper to employ means for conecting the irritating properties of any part of their content! which may still remain, when such means are known. Thus, acids are found useful when there is much bile in the alimentary canal, and absorbents when there is much acid. It is also useful in most cases of fever, to defend the stomach and bowels against the irritation of their contents, by mixing some mucilaginous matter with the drink. On this account water gruel or barley water is generally preferable to plain water, especially at an early period ; in a more advanced stage the contents of the alimentary canal are for the most part inconsiderable. The natural agents, the constant presence of which is necessary to existence, and which cannot therefore be wholly removed, are the circulating fluids and caloric. The quantity of these is to b« diminished in synocha. Of the means of diminishing the temperature of the body in synocha. This is to be done by cool air, cold drink, and the external us« of cold or tepid water. It was observed, when considering cold as a cause of fever, that the temperature of the human body is not diminished by so rare a medium as the air, unless its temperature be under 62Q ; nor in air at this temperature is the caloric disengaged by the human body permitted to accumulate so as to become unpleasant; the rapidity with which it is abstracted is duly proportioned to the quantity evolved. But if the body disengage more calorie than in health, a lower temperature will be required for its due ab- straction. This happens both in synocha, and in most cases of typhus.f In these therefore the temperature of the surrounding air should * Calomel, which has already been mentioned as often serviceable in another way in the fevers of Avarm latitudes, is generally regarded as the best cathartic in these fevers, and many practitioners prefer it to others in die fevers of this country. See the observations of Drs. Wright, Ruilv Chisholm, Sec i Wc have reason to believe, from a variety of experiments, (see the different works on animal temperature) that, wherever the temperature of the body is increased, the blood in a given space of time passes through/ the lungs more frequently than in health, and consequently that die ra- pidity of the circulation is increased. That this should happen in synocha cannot appear suiprising; but in typhus, where the powers supporting CONTINUED FEVERS. •243 always be below 62°. How much below this, will be determined by the temperature ofthe patient. In synocha the temperature is higher than in typhus. In the former therefore, when there is no tendency to local inflammation, a freer application of cold is proper. In well marked synocha the temperature of the patient's bed-room, when the state of the weather permit us sufficiently to diminish it, should never perhaps exceed 35° or 40°, and may often with advantage be still more diminished. It is not meant that it would be proper constantly to expose the body to air of this temperature, but it is better that the proper temperature of the body be preserved by covering, that the pa- tient may enjoy the refreshing effects of breathing a cool atmos- phere. When the temperature ofthe surrounding air is too low, there are many evident ways of raising it. The only circumstances to be attended to in raising the temperature ofthe air in the patient's bed-room are, 1. That it shall be as uniformly raised as possible. 2. That the patient shall not be exposed to a current of air; and a 3. That the proper proportion of oxygen gas in the air shall not be diminished. For the last purpose we have only to take care that no part of the vapour arising from the burning fuel shall be permitted to re- main in the room, and that the external air shall have free access. For heating the patient's bed-room, a stove is preferable per- haps to an open fire, because by it the air may be more uniformly heated, and it is less apt to occasion currents of air. It is not to be overlooked however that a current of air passing through the room, provided the patient is not exposed to it, may for reasons formerly pointed out, be of service hi contagious fevers. It is much to be regretted that we are not possessed of means for lowering equally efficacious with those for raising the tempe- rature of the air. the circulation are weakened, Ave should expect to find the circulation less rapid than in health, and consequently a less quantity of caloric disenga- ged; and this is the case in exquisitely formed typhus, in which the tem- perature of the body falls below the healthy degree. But in other cases of this fever, the increased frequency of contraction in the heart and blood vessels, more than compensating for its feebleness, the rapidity of the cir- culation is increased, and thus a greater quantity of caloric disengaged. In determining the temperature in typhus, Ave should always use the thermometer; if we judge by the feeling, tiie acrid secretion by the skin which occurs in this fever will generally make the temperature seem higher than it really is. This circumstance is particularly to be attended to in the application of cool air, and the external use of cold and tepid Water, in typhus. In the 35th and 36th pages of Dr. Currie's Treatise, above mentioned, lie describes the thermometer, and the manner of using it, which he found most convenient. S44 CONTINUED FEVERS. When from the state of the weather the temperature of the pa- tient's bed-room is too high, which it always is in well marked sy- nocha if it exceed 45°, we have no means capable of diminishing it many degrees; and this seems to be the chief reason of the great fatality of the fevers of warm countries. The hotter the weather, the more fatal the fevers of sultry latitudes are always observed to be ; and it is even said of the yellow fever of the West Indies, that the weather becoming very warm or cool while a person labours under it, is often sufficient to save or destroy him. The only means Ave haA-e of lowering the temperature of the patient's bed-room in Avarm weather, is as much as possible to exclude the light, and frequently sprinkle the floor and other parts of the room with cold water. As in Avarm countries we cannot diminish the temperature of the air of thebed-room many degrees, other means have been pro- posed for diminishing that ofthe patient's body. " Whenever the " patient is in a climate, whose heat is less than 97 degrees of Fa- " renheit's thermometer, which is nearly the heat ofthe body of " the patient, removing the air which is in immediate contact, " by means of putting the atmosphere in motion by any kind of " fan, renders that which is in immediate contact with the body " much colder than it would othenvise be. Such means in case " of too warm an atmosphere seem to be very proper to be cm- " ployed."* " When the object is to diminish heat, that may bo " obtained with great certainty by the repeated use of the tepid " affusion, suffering the surface ofthe body to be exposed in the " interval to the external air; ancl if the beams of the sun are ex- " eluded, and a stream of wind bloAvs over it, the heat may thus " be reduced, where cold Avater cannot be procured, even in the " warmest regions of the earth—on the plains of Bengal or the " sands of Arabia."! Dr. Wright practised a still more effectual method of reducing the febrile heat, but one whose employment requires much caution. " Some lucky expedients, however, " have been practised, which success alone can justify; thus Avhen " the most urgent symptoms had been subdued, the patients were " Avrapt up in a wet blanket, a profuse sweat was brought on, and " an immediate recovery was the consequence."^ For farther observations on the external and internal use of water, as means of diminishing the temperature in fever, the rea- der is referred to what was said when considering the means of inducing sweat. The most important part of the treatment in synocha still re- * See Dr. Fordyce's third Dissertation on Fever. f Dr. Currie's Treatise on the Use of Warm and Cold Water in Fe- vers, &c. X See Annals of Medicine, vol. ii. CONTINUED FEVERS. 245 «a:uns to be considered ; I mean diminishing the quantity ofthe circulating fluids. As the increased excitement of the heart and blood-vessels supports that of every other part of the system ; and as it ap- pears, from the observations made Avhen speaking of blood-let- ting in intermittents and the modus operandi of this remedy, that diminishing the quantity of the blood is the most powerful means of diminishing the action of the heart and blood-vessels ; it is not surprising that blood-letting has been found the most ef- fectual remedy in synocha. It is true indeed, that the mass of circulating .fluids may be diminished by other evacuations, by promoting a discharge from the skin, kidneys, or intestines. The tAvo former we have it not always in our power to command, and although we had, there would still remain the same objection to these as to the last, the discharge by the intestines. This objection has already been considered at «ome length, namely, that in proportion as the evacuation is made more slowly than in blood-letting, it must be carried to a greater extent, in order to produce the same diminu- tion of excitement. On this account it was observed, that pur- ging is to be regarded as a means of diminishing excitement in no other way than by removing from the alimentary canal my cause of irritation, or at most that very mild cathartics are to be employed to aid the more powerful remedy- " But it is to be observed, that as the fluid drawn from the ex- " cretories opening into the intestines, is not all draAvn imme- " diately from the arteries, as a part of it is draAvn from the mu- " cous follicles only ; and as what is more immediately drawn " from the arteries, is drawn off slowly, so the evacuation will " not, in proportion to its quantity, occasion such a sudden dc- " pletion of the red vessels as blood-letting does, and therefore l- cannot operate so powerfully in taking off the phlogistic diathe- " sis of the system. il At the same time as this evacuation may induce a conside- " rable degree of debility, so in those cases where a dangerous " state of debility is likely to occur, purging is to be employed " with a great deal of caution ; and more especially as the due excitement at the commencement be considerable. When, on the contrary, the fever has arisen from cold, from .strong passions, violent exercise, &c. although we know, that if it.be protracted for many days, the symptoms of synocha will be: succeeded by those of typhus, yet Ave have reason to believe, that the synocha will form the principal part of the complaint, and that If the excitement be not permitted to rim high at the commence- ment, the debility towards the termination will not be considerable. In these fevers therefore blood-letting is more frequently proper. The season, climate, and even situation, are not to be over- looked in prescribing blood-letting in fevers. On this part of the subject some observations were made when speaking of the employment of blood-letting in intermittents. 248 CONTINUED FEVERS. This remedy is most to be dreaded in those circumstance* in which the fever is apt suddenly to assume the form of typhus; both because in these cases the symptoms of debility are gener- ally more alarming than where the change is more gradual; and because the typhus supervening soon after the blood-letting, is often attended with fatal consequences. The changes of fevers are more sudden in sultry than in cold and temperate climates, and in large cities than in the country; in autumn than in spring. In sultry climates it is often difficult to determine what is best to be done. At the commencement, the symptoms are sometimes so violent as to endanger life, and yet Ave have no means of diminishing the excitement without the risque of involving the patient in dangers no less alarming. In perusing the works of those who have practised in warm climates, we find them much divided in their opinion respecting the employment of blood-letting in fevers. Some advising the liberal use of the lancet; and others, having frequently experi- enced its dangerous consequences, almost binding themselves by a solemn engagement never to recommend it again in idiopathic fevers within the tropics. In this, as in most other cases, extremes are to be avoided. And there is reason to believe, that we give the patient the best chance of recovery, if we never in such climates recommend blood-letting in idiopathic fever, except when the violence of the excitement threatens to prove fatal, either by carrying off the pa- tient in the height of the synocha, or by the debility which always follows violent excitement, and then only push it to that extent which the urgency of the symptoms absolutely requires. What the symptoms are which mark this degree of excitement, I shall presently endeavour to point out. Although the changes of fever are more sudden, and conse- quently blood-letting more dangerous, in large cities than in th& country, even in temperate climates; yet this case never proves as perplexing as the former. In the populous cities.of tempe- rate climates, the excitement at the commencement of fevers is generally moderate, and there is no occasion for the copious eva- cuations whicii some employ. In most of these fevers venesection is improper. All that is necessary in general is to moderate the excitement at their com- mencement, by clearing the prima via:, ancl other gentle means, till the fever has assumed the form of typhus, and then we must treat it as such. Whether blood-letting is ever proper in typhus, will be considered in laying down the treatment of that species of fever. The same observation applies to the autumnal levers of temperate climates ; the excitement is rarely such as warrants the use of blood-letting. The next circumstance which demands attention in recom- CONTINUED FEVERS. 249 mending blood-letting in idiopathic fever, is the degree of excite- ment present. In determining the degree of excitement which warrants , blood-letting, we are influenced by the observations just made ; for the same degree of excitement Avhich would induce us to re- commend this remedy when the epidemic partakes much of the synocha, does not warrant its employment when the prevalent symptoms are those of typhus. The same degree of excitement which indicates blood-letting when the fever has arisen from cold, from rage, or violent exer- cise, does not indicate it in fevers from putrid effluvia or conta- gion. In the latter case, although the excitement at an early pe- riod be considerable, Ave knoAV that the nature of the fever will soon overcome it. In the other, if the excitement is not dimin- ished at the commencement, there is reason to believe that it will increase, while at the same time we know that the debilitating ef- fects of blood-letting in this case are less to be dreaded. Let the nature of the fever be what it may, however, the fol- loAving observation is to be kept in view : That violent excite- ment is itself a highly debilitating cause, and often debilitates more than a well-timed blood-letting which relieves it. Lastly, the degree of excitement which warrants blood-letting in tlie cold and temperate climates and in the country, does not warrant it in sultry climates and large cities, because in the latter cases we in general dread more the diminution than the excess* of excitement. From these observations it is evident, that no general rule can be laid doAvn respecting the degree of excitement in fevers which demands blood-letting. The determination of this question, un- less the violence of excitement be extreme, depends as much on the consideration of the circumstances just mentioned, as the symptoms present. When the excitement is such as to be accompanied with deli- rium, which Avhen it arises from violent excitement is of the furi-r ous kind, or when coma, Avhich more rarely happens, appears in well marked synocha, we must always have recourse to blood- letting. In temperate climates the symptoms of synocha seldom run so high, and almost never in any of those circumstances which ren- der blood-letting dangerous. In sultry climates they often do, and then as the affection of the brain either in the furious delirium or coma seems to increase the general excitement, (as most local affections allied to inflammation do) it may often be adviseable to try the effects of local means, particularly leeches applied to the head or scarification of the temples, before we have recourse to general blood-letting. Vol. I. H h i30 CONTINUED FEVERS. Delirium is mentioned as a symptom denoting a degree of ex- citement which renders blood-letting necessary in all cases of sy- nocha : But in general it is indicated by a much less degree. If the face be flushed, the pulse full and strong, and the heat consi- derable, this remedy to a greater or less extent is usually employ. ed with advantage.* There are other circumstances to be considered in the employ- ment of blood-letting in fever. Among these is the period of tlie ! disease. What was said on this head when speak.ug of in- i.^. ting is nearly applicable to continued fevers. As soon ti> • ie symptomsof synocha begin to decline, the proper period for blood- letting is past. Even Huxham, prejudiced as he and most of is cotemporaries were in favour of this remedy, admits in his treat- ise, on fevers, that " bleeding, unless in the beginning, seldom dri " service." The age, vigour, and plethoric state of the patient are also to bt ' attended to. Young people, it has already been observed, and people in the vigour of life, bear evacuations of all kinds better than those advanced in age. The same may be said of people of a full habit, compared with such as are naturally infirm or reduced by disease or other causes. The patient's former diseases and habits of blood-letting arc also to be considered ; if he has been subject to inflammatory com- plaints, these are apt to be renewed on slight occasions; and con- sequently symptoms indicating their approach must often be re- moved by more vigorous means than are necessary for the remo- val of the same symptoms in those who have not been subject to such complaints. If the patient has been in the habit of losing blood, it is often proper to enr^y this remedy where it Avould not otherwise have been nece- .y. Habitual blood-letting pro- duces habitual plethora, whic. constantly demands a repetition of the same remedy. We must attend to the appearance of the blood drawn, in order to determine the propriety of repeating the blood-letting. There are three morbid states ofthe blood which have particu- larly demande'd tlie attention of physicians. 1. Where there is much of the inflammatory diathesis, the blood is either more fluid or coagulates more slowly than natural, I so that the red globules in part subside before the coagulum is formed. Hence there are no red globules en the upper part of the coagulum, which on this account'appear s\f a buff colour, and has been termed the buffy coat. In different cases it is thicker j * Blood-letting in infants, Vogel observes, is not necessaiy in the syno- { ch •; nor is it necessary in adults, unless the face be red, the head much J named, the pulse very full, or blood bursts from tlie nose, except when '< tlie mind is deranged, or the fever has arisen from tiie abuse of spirituous- liquors. Frwlect.-Acad.de Cog..etCur..Moi-b.. _ CONTINUED FEVERS. 25* >*r thinner, according as the blood has remained fluid for a longer or shorter time. The thicker the buffy coat is, it generally indi- cates the greater degree of inflammatory diathesis. The buffy coat however, though for the most part, does not universally in- dicate the presence of this diathesis, nor does it universally ap- pear when the diathesis is present. I shall afterwards have occa- sion to observe more particularly, that the buffy coat is sometimes, though rarely, absent even in cases of actual inflammation, and now and then it appears when the system is in a stale very oppo- site to the inflammatory diathesis. The buffy coat may also appear thicker or thinner, or its ap- pearance may be wholly prevented, by the circumstances of the blood-letting. If the blood flows sloAvly, and is permitted to trickle down the arm, the coagulation will begin before it reaches the vessel, and consequently the red globules, if they subside at all, will subside more slowly. If the blood is received into a broad shallow vessel, it will coagulate more quickly than if received into a narrow deep vessel, and the buffy coat consequently will be thin- ner in the former case. These circumstances therefore are to be attended to in forming our judgment from the buffy coat. When this coat appears, the crassamentum is generally firm, and that part which forms this coat being free from red globules, is firmer than the crassamentum of healthy blood, which is every where crowded with globules that diminish its cohesion, in the same way as any other powder would do. 2. There is a light kind of blood in which there are compara- tively feAv red globules, and the proportion of water is too great. Such is the state of the blood in many diseases of debility, in the typhus mitior, the different kinds of dropsy, &c. 3. The last kind of blood is found in the vessels of those labour- ing under typhus gravior and scurvy. It has a dissolved appear- ance, does not coagulate so readily as healthy blood, the serum is of a redder colour than natural, ancl the crassamentum of a looser consistence.* If the blood drawn in fever be! of the first kind, if after stand- ing some hours it be covered with the buffy coat, this gives en- couragement for repeating the blood-letting, should the symp- toms seem to require it. If, on the contrary, the blood be of the second or last kind, we have committed a serious error in recommending venesection, a repetition of Avhich might destroy the patient. In determining the propriety of repeating the blood-letting, we must also attend to the effects it has produced. It the symp- * Tlie different appearances which this kind of blood assumes are well described in a quotation from Dr. Fordyce's third Dissertation on Fevei;, given when enumerating the symptoms of continued fever. 252 CONTINUED FEVERS. toms are alleviated, if the pulse from being strong and full be- comes nearly natural, and the heat is diminished, there is no oc- casion for repeating the blood-letting. If the strength is much reduced, if the complaint begins to assume the form of typhus, which sometimes very suddenly happens after an ill-timed or ex- cessive blood-letting, the repetition of this evacuation Avould be attended with the worst consequences. If, on the other hand, the symptoms continue unabated, the operation must be repeated to at least the same extent. Lastly, if the symptoms still con- tinue, but with a considerable abatement, it will be proper to repeat the blood-letting as soon as they begin to suffer an exacer- bation, which very often happens, till the operation has been per- formed several times.* It appears from what was said of the modus operandi of blood- letting, that it is the more effectual, the more suddenly the blood is abstracted. On this account it A\as once the practice to let blood from both the arms at the same time. It is enough howev- er to make the orifice pretty large, a circumstance not always sufficiently attended to by surgeons. For the same reason that Ave abstract the blood suddenly, namely, that the action of the powers supporting circulation may be diminished with as little loss of blood as possible ; some have recommended, in those cases where much is to be feared from a considerable loss of blood, to keep the patient more or less in the erect posture during the blood-letting, in order to induce a de- gree of syncope by a small loss of blood. This in idiopathic fe- vers is not to be attempted. In certain circumstances, hereafter to be pointed out, I have known it practised in the phlegmasia; with success, but it requires much caution and discernment to practise it with safety. In general the horizontal posture is preferred, that we may not be prevented by a tendency to syncope from taking away the proper quantity of blood. In this posture many can bear the loss of 16 or 18 ounces with ease, Avho could not in the erect posture lose half the qantity without falling into syncope. Every cause which diminishes the flow of blood to the brain tends to induce, and every cause that increases it to prevent, syncope. It is in * It sometimes, though rarely, happens in fevers, that the excitement, instead of being diminished, increases after blood-letting ; a cii cum- stance which might disconcert a practitioner not aware ct it. In very plethoric habits the quantity of blood seems sometimes to oppress the powers supporting circulation, so that it is not moved with the rapidity which is necessary to occasion tiie symptoms of violent excitement Al- though fsays Van Swieten) the most necessaiy and only remedy in vio- lent fever is blood-letting, yet it sometimes happens in plethoric people, that after venesection the fever from being low becomes very violent He relates two cases of this kind, one from Sydenham's works, and another which Jeerhaave used to relate in his lectures en fevers. Similar cases are to be found in the works of Dr. Rush and others. In such cases the blood-letting is to be repeated as in other cases cf sy- Rccha, till the excitement is sufficiently diminished. CONTINUED FEVERS. S53 this A*ay that the horizontal posture, by which the flow of blood towards the brain is increased, and its return rendered less rapid, is serviceable in blood-letting. In general blood-letting, that is, when our only view in letting blood is to relieve a state of general excitement, it is of no conse- quence from Avhat part of the body the biood is taken. The most convenient place therefore, the arm, is generally chosen. "But when there is present any local affection which may be relie- ved by blood-letting, by abstracting the blood from the part affected or its ncigbourhood, the same operation may answer the purpose both of general and local blood-letting. Thus when deiirium or coma supervenes in synocha, it is better to take the blood from the jugular vein, if this can be readily made to swell, than from the arm. The following caution is to be attended to in bleeding from the jugular in affections of the head : to compress that vein alone from which the blood is about to be taken. A ligature thrown round the neck in such cases, though not very tight, may be attended with dangerous consequences. There is perhaps no case Avhich Avarrants our carrying blood- letting So far as many of the ancients recommend. Copious ancl early blood-letting, Hoffman observes, is in no fever more requi- site than in the synocha. But we are not to follow the advice of some of the ancients, of letting the blood flow till the patient faints ; it is better to repeat the operation than to take away too much at once. It is generally regarded as an undoubted maxim in the treat- ment of fevers, that we are not to let blood, give cathartics, or in any manner disturb the system by medicines, when an eruption, or any other of those symptoms which are esteemed critical, makes its appearance. A question of some consequence, says Hasenhorl, may be considered here, whether it is proper to let blood in fevers when an eruption appears upon the skin. EAery one believes, he adds, that Ave are not by any efforts ot" art, such as blood-letting, catharsis, vomiting, sweating, to disturb the opera- tions of nature, when there is reason to expect a crisis. He just- ly observes, hoAvever, of this maxim, that " juxta illud vulgare nulla regula sine exceptione," and gives the case of pleurisy as an exception to it. He might have added, not only all cases of visceral inflammation, but those also where an eruption Or other critical symptom appears in the synocha without relieving the symptoms. When the state of the symptoms requires both blood-letting and the exhibition of an emetic, the blood-letting should always precede the emetic. One thing, Sydenham observes, is not be overlooked ; if the condition ofthe sick be such as to require both vomiting and blood-letting, let the blood-letting precede the em- etic ; for I could mention several cases, he continue:;, in Avhich the efforts of vomiting produced such a flow of b.'ood to the he .id 254 CONTINUED FEVERS. that a rupture of some of the vessels of the encephalon and a Ta- tal apoplexy were the consequence. A similar observation applies to blistering, when it is judged necessary at the same time with blood-letting. The blister should be delayed till after the blood-letting, because its irritation will be less hurtful when the excitement has been diminished. Such are the circumstances to be attended to in the employ- ment of blood-letting in synocha.. Evacuations, however, are not the only means of diminishing the quantity of blood. The quantity of this fluid depends on that of the ingesta, and it may be so diminished by abstinence as in a 6hort time to endanger life. When the excitement runs very high we recommend both evacuations and abstinence ; but when it becomes more mode- rate, or in cases where it has never been considerable, we recom- mend neither. It is then sufficient to employ those means w hick- diminish the stimulating power of the blood and ingesta ; these 1 am now to point out. The last means of fulfilling the indication in synocha are those which diminish the stimulating power of such of the natural agents as cannot be wholly removed. These are, caloric, the circulating fluids, and if the synocha be of considerable duration, food. We have no means of diminishing the stimulating power of caloric ; it is only to the circulating fluids therefore, arid food, that this indication applies. As the quantity of blood cannot be much diminished without debilitating every function of the system, it is of consequence Avhere the symptoms run high, to lessen as much as we can its stimulating power, that the excitement may be diminished with as little evacuation as possible. The means of diminishing the stimulating power of the blood are, 1. Dilution, and 2. The medicines which have been termed refrigerant. There is a large proportion of water in the blood, to Avhich k OAves its fluidity ; and the stimulating power of the blood, its quantity being the same, is inversely as the degree in which its saline and other stimulating parts tfre diluted. Dilution therefore is the most successful means of diminishing its stimulating pow- er, and that Avhich nature by an increase of thirst points out in all cases of excessive excitement. In typhus there is often little or no thirst ; but in synocha . it is generally insatiable. Every person in this fever, Van Swieten remarks, unless, his intellects he deranged, is led by instinct to demand water and watery liquids. CONTINUED FEVERS. sj-3 us instinct best points out the quantity of such liquids which .1 • isary. We are neither, as was once a practice, and there ^ouid not be a more improper one, to prevent the patient from satisfying his thirst, nor to run into the extreme of the Dieta Aquea ofthe Spanish and Italian physicians, and force the patient to take every day eight or nine pounds of water.* When the excitement is considerable, diluting liquids should also be injected per anum. Sydenham made much use of clys- ters composed of a mild A'egetable decoction and sugar, or of milk and water heated to the proper temperature ; and so powerful did he find these means in allaying excitement, that he cautions against the immoderate use of them, least the excitement be brought too low. Celsus has justly observed, that clysters are proper where blood-letting is indicated, but the weakness of the patient prevents us employing it, and in those cases where the period proper for blood-letting is past. Dilution is also the chief means of diminishing the stimulus of the food. The food of a patient in synocha, when food is judged to be proper in this fever, should consist wholly of mild decoc- tions, thick barley water, or water gruel, or water thickened with sago. Fresh acidulous fruits make an excellent addition to this diet. These belong to the head of refrigerants, the last set of medi- cines in the treatment of synocha. The chief of this class of medicines are acids and neutral salts. They act by cUminishing tlie stimulating power of the food and blood. If the contents of the stomach and boAvels stimulate more than they ought to do, the frequency of the pulse and heat are increas- ed, and temporary fever is the consequence, which may be re- lieved, and often wholly removed, by receiving into the stomach a quantity of acid or some neutral salt. Thus people drink le- mon juice, or cream of tartar, with distilled spirits, to moderate their stimulus.! Refrigerants also, although in a less degree, allay the atonic power of agentsi, and on this account many of them, particular" * See an account ofthe Dieta Aquea, in the 36th volume ofthe Philo- sophical Transactions. f It mav here be alleged, that refrigerants do not diminish the excite- ment by diminishing the stimulating power of the blood and food, but by diminishing the excitability of the living solid ; and it must be confessed, that it is difficult to determine in which of these ways they act. X A similar objection may be started here. We cannot determine, and it would be of no consequence in the treatment of fever although we could, whether refrigerants diminish the atonic poAver of agents, or the atonic state ofthe living solid. We have reason to believe that they act in the former way, because whatever else tends to correct tlie atonic srate of *he living solid, increases excitement, which refrigerants [end to diminish 256 CONTINUED FEVERS. ly acids, are serviceable in typhus as well as synocha, especially in warm climates. We shall find, however, that in the former, from their tendency to diminish excitement, they must be em- ployed Avith caution. The best refrigerants were pointed out when considering the treatment in the paroxysm of an intermittent. " Some metallic " salts," Dr. Cullen observes, " have been employed as refrige- « rants in fevers, ancl particularly the sugar of lead. But the " refrigerant powers of this are not well ascertained, and itsde- " leterious qualities are too well known to admit of its being " freely used." Ofthe Treatment in Typhus. The indication in typhus, it has been observed, is to change the state of atony into that of moderate excitement; which is to be effected, 1. By removing as far as can be done with safety the natural agents which now act as atonies ; and 2. By applying those agents which still act as stimuli. In removing or diminishing the quantity of the natural agents in typhus, one caution is ever to be kept in view ; that Ave do not weaken the action of the powers necessary to life, whose ac- tion in typhus is already weaker than it ought to be. Although therefore we are here, as in synocha, to avoid the application of those agents which excite the animal functions, we must be cau- tious in diminishing the quantity of those on which the vital func- tions depend. It is true indeed that these, like the other natural agents, excite a morbid action in typhus; but this action is capable of sustaining life for a certain length of time, and Ave can only re- move it Avith safety by substituting a more healthy action in its stead. The agents which excite the mind and organs of sense are not necessary to our existence ; they may all be withdrawn without diminishing the povvers of life ; and as they excite a morbid ac- tion in all kinds of fever, they must be avoided in the typhus as well as in the synocha. But with respect to the agents that sup- port those powers on which life depends, the indication in synocha ancl typhus is different. In the former, as they occasion too powerful an action, the indication is to diminish the quantity ap- plied. In the latter, in which the action of the vital powers is too weak, we must abstract with caution the agents which support it, and only guard against their excessive application. The principal of these agents is the blood. The excessive ap- plication of this agent in typhus is not to be feared, since its quan- tity must always be less than in health; the quantity of chyle for.ncd being greatly less. It is even necessary, wc bhall findi CONTINUED FEVERS. 257 In typhus to use every means in our poAver to increase the quan- tity of blood. The only agent necessary to the existence ofthe vital functions, which is often applied in excess in typhus, is caloric ; but in re- moving the excess of caloric evolved in this fever, we must be cautious not to diminish the temperature below the healthy de- gree ; and where, as frequently happens, the powers of life so far fail, that the temperature falls below this degree, we must endea- vour to raise it by artificial means. The agents which excite the natural functions, are neither of such immediate importance to the preservation of life as those on which the vital functions depend, nor are they so little essential to it as those which support the animal functions ; and in the treatment of typhus, we shall find, that although the constant application of these agents in the due degree is not so necessary as that of those which support the vital functions, yet they are never, like the agents that excite the animal functions, to be wholly abstracted in this fever. While we thus manage the application of the various natural agents, we are at the same time to employ those agents which more directly tend to remove the morbid condition of the living solid; the cause of the disease. Experience has informed us, that if we succeed in supporting a certain degree of excitement, this morbid state Avill be removed. This fact is neither the less certain nor the less valuable, because we are unable to explain it. We shall find, that with the exception ofthe proper management of the natural agents and the crises of fevers, it suggests every thing that has been found serviceable in typhus. Such is the outline of the treatment in typhus, and the princi- ples which conduct our practice in all idiopathic fevers in which the symptoms of typhus prevail. We are now to take a mor* detailed view of the subject. I. Of the management of the natural agents in typhus. Of the agents on which the animal and natural functions de- pend. Of the agents which excite the animal functions there is little to be added to what has already been said. Wherever the symp- toms of typhus are considerable, they must be avoided, Avith the exception pointed out by Dr. Cullen, Avhich I have already had occasion to notice. In the typhus mitior hoAvever, which is often protracted for a great length of time, and in Avhich the febrile symptoms are mild, a moderate application of these agents is of- ten beneficial, particularly the exertion of sitting up a feiv hours during the day, or, if the weather be mild, of being carried into the open air.* Much caution, however, is requisite in exciting the mind and organs of sense in fever. * Sydenham observes of this fever, that much benefit is derived frons Vol. I. I i 239- CONTINUED FEVERS. The agenfs on which the natural functions depend, demand more attention in typhus than in synocha, both on account of tho debility which attends the former, and because it is a complaint of longer continuance. As the powers of digestion in all fevers are much debilitated, every thing apt to derange these powers is to be avoided. Both for this reason, and because the presence of much food in the stomach is hurtful in all kinds of fever, the quantity taken at ono time should be small; but in Avell marked typhus it ought to be repeated as often as the patient can take it Avithout oppression. Jt is our vieAy in typhus to restore the vigour of the system, and one means of effecting this, is to procure as considerable a supply ol chyle as the state of the digestive organs admits of. It is doubtful if the irritation of animal food is proper in any kind of lever, when the symptoms run high. In the typhus mi- tior, especially av hen of long continuance, the lighter kinds of animal food, chicken, veal broth, or calf's foot jelly, are perhaps the best kind of nourishment; in other cases farinaceous matter, combined with water and coagulated by caloric, seems preferable. It is neither acescent nor flatulent, it is easy of digestion and gives little irritation. We shall find, that in typhus it is proper to combine it with Avine ; but of Avine I shall afterwards have occa- sion to speak at greater length. Fresh fruits are proper articles of diet in all kinds of fevers, especially those that contain a considerable quantity of acid ;* and where it is our view to nourish as much as possible, the more farinaceous kinds, such as peaches, are useful. Many fruits are rendered less acescent and more nourishing by being boiled or baked. Roasted and boiled apples are good articles of diet in le- vers, but are less nourishing than the farinaceous vegetables. Farinaceous matter may also be mixed with the patient's drink. Barley water or water gruel, acidulated with lemon juice and mixed with a proper quantity of wine, is the best drink in typhus; and by varying the proportion of the ingredients, the patient can raising the patient from his bed and making him sit up for a short time. i here are instances," say? Dr. Moore, " of patients in the nervous fe- ci Vu r' u e ]'J ing in bed thouSht their strength so much exhausted that they could not sit m an erect posture even for a few minutes, vet on || being earned on a couch into the open air and remaining there for two || or three hours have been so much refreshed, and have required sr-ch an " accession ot strength or spirits, as not only to sit up, but even stand, or " Ava.k a little." ' *Oranges aid lemons are very generally recommended in typhus, and the Asiatics m those countries where malignant fevers are prevalent, con- sider the juice of lemons as among the most poAverful remedies in such compb-.nts. It may seem to imply a contradiction tc forbid the me vi acescent food and recommend that of acids. Acescent food, how ever, at the same time that it produces an acid, occasions flamlence, and other- av i-e impedes digestion; whereas an acid received into the stomach, is often found to promote it- CONTINUED FEVERS. £59 be made to relish it perhaps longer than any other. All kinds of sweets ancl aromatics soon become disgustful to febrile patients; and for common drink there is no better substitute for that just mentioned, than small beer or butter milk, which are generally very grateful to them. Any of these drinks are preferable to plain Avater in typhus. In all fevers the peristaltic motion of the intestines is lessened, so that artificial means become necessary for the regular expulsion ofthe fxces, or any other irritating matter which the intestines may contain; the only purpose for which we ought to move the boAvels in typhus. In this fever those cathartics should be preferred which occa- sion the least evacuation, rhubarb, aloes,* &c. and neutral salts in particular should be avoided, not only because they generally occasion a more copious evacuation, but because refrigerants, if we except acids, are usually hurtful in typhus. When several laxatives are mixed together, Dr. Fordyce observes, they occasion sickness and pain, and are more certain in their operation than when taken singly. It is only however in the earlier stages of the disease, when the contents of the alimentary canal may be considerable, that cathartics of any kind are well suited to typhus.f When the dis- ease has lasted for some time, ancl from the diminution of the in- gesta there is little matter in the intestines, it is better, because it is less debilitating, to procure the regular expulsion of the fxces by clysters ;\ and it is proper to use the clyster in the evening, that as feAv causes as possible may conspire to prevent sleep, one of the most favourable symptoms of fever. Besides removing as far as possible the agents Avhich tend to prevent sleep, most practitioners diminish the sensibility to those still applied by opiumin all cases of fever where the excitement is not considerable. * " Vomitoria et purgantia nunquam adniittenda sunt, nisi adsit certi- " tudo, quod alimentum Aitiosum adsumtum, utpoma vel prima immatura " et frigore comipta, febri malign* ansam dederint, vires adhuc sufficiant, " nee aliud coatraindicans adsit; sed a vomitorio fortiori, vel a purgante " drastico abstinenduin " See a Paper on Typhus by Hilscher, in the 5th vol. of Haller's Disp. ad Morb. Hist, et Cur. Fertin. f It has long been a prevalent opinion, (see the works of Hoffman and others) that purging should be induced in the decline of all fevers, in order, as we are informed, to purge off the dregs of the disease. When we speak of the exanthemata, we shall see the source from Avhich this prejudice took its rise. It is sufficient at present to observe, that in fevers properly so cnlled, the practice is universally pernicious. X From the prejudicial effects of diarrhoea in the plague, the popular dread of all kinds of cathartics in Eastern countries is such, that the na- tives in that complaint often refuse to submit to any means cf evacuating the fxces, which are frequently retained for many days, and sometimes f u draAvn 24 hours after is commonly livid, black, and too thin, iv u third quantity livid, dissolved, and sanious ; this is frequently " the case in malignant fevers. I have sometimes observed," he continues, " the crasis of the blood so broken as to deposit a " black powder like soot at the bottom, the superior part being a « livid gore, or a kind of a dark green and exceedingly soft jelly. " Besides the pulse in these cases sinks oftentimes surprisingly " after a second bleeding, nay sometimes after the first, and this « I have more than once noted to my great concern and astonish- " ment, and that even where I thought I had sufficient indications " from the pulse to draw blood a second time.* In his Essay on the Ulcerous Sore-throat, the same author ob- serves, a I have very often met with this buffy or sizy appearance " of the blood in the beginning of malignant fevers,! and yet " blood drawn two or three days after from the very same person " hath been quite loose, dissolved, and sanious as it were ; too " many instances of this lately occurred to me among the French " captives here avIio died by dozens of a pestilential fever. In this " fever the French surgeons bled every day, or every second day, " and I several times saAv the blood of some of the officers a mere 11 sanious gore on the third or fourth bloed-letting.J Eller observes of one of his patients who laboured under a pu- trid fever ; although he was bled copiously during the first days of the complaint, the symptoms grew Avorse. Dr. Donald Mon- ro says, that he was often obliged to give cordials to support the patient's strength after blood-letting ; it is remarked by Sir John Pringle, that many have recovered from the jail fever without blood-letting, but very few who had lost much blood ; and Hoff- man confesses, that in many cases of fever it is very difficult tu determine whether or not we ought to have recourse to this reme- dy. It seems well ascertained by succeeding observations, how- ever, that it Avas employed by all the foregoing practitioners, in cases where it did much harm. Dr. Monro, who is among the latest, endeavours to support his practice less by his OAvn experi- * Huxham on Fevers. f From these and similar observations it appear?, that the buffy coat sometimes covers the blood in cases where it certainly neither indicates a repetition of the blood-letting, nor the propriety of having had recourse tdrt. "f: Huxham was led at length to see the impropriety of blood-letting in most cases "f typhus, and he confesses that in those Fevers which arise from contagion it is generally followed by bad consequences. lie otters the reason wf this in the following manner. " The contagion being diffus-« " ed through the whole mass of blotxl, you will little lessen it by drawing " off a small quantity of this fluid." On this passage Dr. Moore ob- serves, " The reason here assigned for bleeding not being indicated, is " unquestionably verv ingenious ; but the reason which makes tlie strong- v est impression on niy mind for not bleeding in tins lever, is simply Us- '* cause it seems geaei-ally to do harm," 264 CONTINUED FEVERS. ence, than the authority of Hassenohrl, who again supports his, not by facts, but by opinions, such as those just quoted from his works, respecting' the supposed viscidity of the blood ancl the means of correcting it. Thus we find the authors who recommend blood-letting in ty- phus, founding their practice on hypothesis, and at the same time relating facts which invalidate every thing they say concerning the state of the blood and the modus operandi of blood-letting in fevers. While it is acknowledged, even by the warmest advocates for blood-letting in typhus, that its bad effects are often apparent, we are led naturaily to expect some account of the beneficial ef- fects Avhich induced them to persevere in recommending it. For these however we look in vain. It is true indeed that a feAv scat- tered instances may be collected, in which blood-letting seem- ed to prove serviceable in typhus. The most remarkable in- stance of this kind which I have met with, is a short account of an epidemic, which Dr. Donald Munro gives from Riverius. Af- ter he had attended several patients, labouring under what ap- peared to be a common malignant fever, attended with a swelling ofthe parotids, who died without these glands coming to suppu- ration, he formed a theory concerning morbific matter in the blood, which led him to recommend blood-letting. From the next patient he attended, he took away three ounces of blood, although the patient Avas so weak that the surgeon thought he would have died under the operation ; after the evacuation how- ever the pulse rose, and in a few hours four ounces more were taken, after which the pulse continued to rise, and the patient was restored to health. Riverius asserts that all those who were treated in this manner recovered. Nobody acquainted with the nature of fever will regard solita- ry instances of this kind as capable of influencing the inference which general observation warrants. Singularities are constant- ly observed in particular epidemics, from which no inference can be draAvn respecting fever in general. There are many reasons to induce us to believe, that the epi- demic described by Riverius was attended with some abdominal inflammation ; the effects of the blood-letting were precisely such as they generally are in these inflammations. Visceral in- flammations are often present, as dissection iti'ter death has shewn, when none of the symptoms seem to indicate their presence. This is particularly apt to happen in feAers. It happened fre- quently, for instance, in the fever of Grenada, described by Dr. Chisholm, and may account for the practice which was found most successful in that fever, and which in typhus:, unaccompa- nied by any local affection, would prove highly pernicious. There are even cases, related by de Haen, in which inflanimaiion 6f the stomach was the only or principal complaint ; and yet the CONTINUED FEVERS. 265 patient complained neither of pain, nor the other symptoms which denote its presence. If the above epidemic was a simple typhus, why is not blood- letting useful in other cases of this fever ? Is not this circum- stance alone sufficient to demonstrate that there was something peculiar in the epidemic described by Riverius ?* The inference from the facts which have been laid before the reader is very plain, namely, that blood-letting is not to be em- ployed in simple typhus. The most important part of the treatment in typhus stiil re- mains to be considered. II. Of the means of increasing the excitement in typhus. The agents which have been employed most successfully for this purpose are, opium, wine, the bark, and cold water used ex- ternally. I have already had occasion to make some observations on the use of opium in fever as a soporific. It has also been employed in typhus as a stimulus, and some practitioners, particularly the late Dr. Brown, prescribed it in very large doses. In that kind of typhus where the delirium is considerable Avithout partaking of coma, it is a powerful medicine, removing the delirium, dimi- nishing the frequency, and increasing the strength of the pulse. Nor can there be a doubt that the use of large doses of opium in such cases would soon have become general, were it not that Ave possess another medicine, Avine, capable of producing the same effects, and on other accounts, particularly the greater perma- nency of its good effects, preferable to opium. On this account most practitioners have properly abandoned the practice of giving very large doses of opium in typhus, and * Blood-letting, and other evacuations, produced the same effect as in this epidemic in the fever of Philadelphia, which we are well assured Avas attended with local inflammation. Purging, says Rush, raised the pulse when low, ancl reduced it when pretematurally tense; it revived and strengthened the patient; it often produced sweats after the most pow- erful sudorifics were given in vain ; it sometimes checked the vomiting at the beginning, and assisted in preventing the more alarming recur- rence of it about the 4th or 5th day. Blood-letting, the same author observes, in other places, not only rais- ed the pulse when depressed, but quickened it when pretematurally slow and subject to intermissions ; it reduced its frequency and force when these were too great; checked vomiting ; and lc-Lsered the difficulty of opening the bowels. Dr. YVoodhouse, he informs us, often sa.v purging begin Avhiie the blood flowed from the arm ; it removed deliiium, coma, and obstinate watching ; it obviated tlie hemorrhagic tendency; son eames disposed to gentle perspiration ; and lessened debility. The dilate-1 pupil sometimes contracted after blood-letting. It east-d pain. The Mania sometimes increased after the first or second blood-letting, but yielded tj the repeated use of the same remedy. The proper treatment of the fevers of sultry climates can never be as- cert lined, till the nature ofthe local affections vyhich accompany theni is better investigated than has hitherto been dose. Vol.. I. K k a&6 CONTINUED FEVERS. use it only as a soporific, while they employ as a stimulus, a me- dicine which from every observation on the subject is better fitted for this purpose. But in those sudden sinkings which sometimes happen in typhus, where the danger is great and immediate, we have still reason to believe that large doses of opium may some- times be useful, especially when it is impossible, as often happens, to exhibit the necessary quantity of Avine. In such cases, it is said, a large dose of opium has sometimes snatched the patient from the very jaws of death. But on this part of the subject our obser- vations are at present very defective. It is only since the un- guarded practice of Dr. Brown sheAved Avhat may sometimes be done with safety, that opium has been employed with much free- dom in fevers. Some physicians run to the opposite extreme, and regard opi- um as hurtful in fevers, unless employed in doses so small, that they can hardly be supposed capable of producing any important effect. " About five and twenty years ago," Dr. Fordyce observes, " there arose a practice in St. Thomas's Hospital of exhibiting " opium in a much less quantity, to wit, in the quantity of a quarter " of a grain for a dose, and repeating it at the end of every six or " eight hours. When given in such doses it produces no imme- " diate effect, but by degrees the patient falls into a stupor, Avhich " gradually increases; ancl although the stupor does not end in a " complete sleep, yet it grows in a day or tAvo into that kind of " stupor that we find when the delirium from the fever, with ap. " parent fulness ofthe vessels of the brain, begins to diminish. Itis " true indeed, that this dose of opium is obtained by addinga few " drops of laudanum to that mixture which is called mithridate; " but the author has often employed the opium in his private prac- " tice with ten grains of castor with equal or rather better effect. " Lately many practitioners have exhibited.opium three or four " times in the twenty-four hours in fevers, having borrowed their "•practice probably from that which has been pursued in St. Tho- " mas's Hospital, the practice of the hospital being open to the " inspection of many pupils. These practitioners have notleam- " ed hoAvever that it is the smallness of the dose that produc.es " beneficial effects; if the dose be increased so far as half a grain, " the same restlessness, the same disturbed sleep, dreams, &c " as have been noticed are brought on." Moderate doses of opium produce these effects only when given without a due attention to the circumstances mentioned when speaking cf it as a soporific. Upon the. whole, the result of the observations on this part of the subject appears to be, that for the purpose of procuring sleep, moderate doses of opium may with proper care be employed in all fevers Avhere the excitement is not considerable, but that it is rarely to be exhibited in these complaints Avith any other view.* * It is remarkable with how much caution the older practitioners speak CONTINUED FEVERS. 26? For increasing the excitement in typhus, wine is the most pow- erful medicine we possess. It is only lately thatit has been used with much freedom in fevers. Its beneficial effects in the various forms of typhus, however, are now so well ascertained, that in all cases where this fever is not cut short at an early period, it is the medicine on which Ave almost wholly rely. Sydenham and his cotemporaries made little use of Avine in fe- vers ; since his time we find the practice gradually gaining ground. Most of the best later writers however, Hoffman, Bo- erhaave, Van Swieten, Huxham, Mead, De Haen, Hassenohrl, El- ler, Pringle, Monro, Sec. have erred, in recommending wine too sparingly in typhus. Dr. Cullen is among the first who recommended it in large quantities, and to compensate for the harm which the Brunonian system has probably done, it has been a principal means of ex- tending the use of this valuable medicine. I have no where met with better observations on the use of Avine in typhus, than in Dr. Moore's Medical Sketches ; and I quote his observations, in preference to those of any systematic writer, because he is not attached to any hypothesis, and merely relates with accuracy what fell under his OAvn observation. His remarks, however, are not,here given as the result of his own ob- servation alone, but, I may say, of the medical faculty of Great Britain for the last fifteen or twenty years ; for during that peri- od there is no British practitioner of eminence whose observa- tions, as far as they are known to the public,* do not tend to con- firm those I am about to quote. It will appear, from the remarks which it Avill be necessary to make on what Dr. Moore says, that even he in certain circumstances did not employ wine with the freedom which repeated observation has now ascertained to be proper. Of the medicines employed for the diminution of excitement it may be observed, that they are to be had recourse to only when of the use of opium in continued fever. " Si febre jam pulsa," says Sy- denham, " fracriores adhuc essent, ac magis effetaj aigri vires, atque si " tardius convalesceret, quod Ivy sterlets frequentissime accidebat, laudano " in parva dosi exhibito, easdem restaurare et spiritus transfugos ac dissi- " patos, indesertas stationes revocare, conabar. Kara autem remedium *'• illud repetebam neque unquam prescripsi nisi biduo triduoAc apostiema 'Vcathai-hi." On another occasion, however, he observes, that he often recommended opium after the operation of an emetic, " ut tumukum ab " emetico in humaribus excitatum consopiam et quietem conciiiem." In a letter to J. liedley by Dr. Martin Wall, the reader will find an ac- ceunt of some cases of typhus treated Avith opium, For the use of opi- um in fevers he may also consult Dr. Liiid's Treatise on Fevers and In- fections; Dr. Blaue's Treatise on the Disua&e.-i of Seamen, and Dr. Campbell's on the Fever of Lancashire. * I allude chiefly to the lectures of professors in the different medical schools, and to the observations of many cf the best practitioners, which hive occasionally appeared in the various pei iodic works established ia Creat Britain. 3€8 CONTINUED FEVERS. they are absolutely necessary ; of those which increase excite- ment that they are to be employed Avherever they are not abso- lutely hurtful. The former are often attended with the worst consequences even where necessity obliges us to have recourse to them ; the latter are often beneficial av here they are not ne- cessary. There is no remedy to which the last remark is more applicable than wine. "When the pulse is soft and f.:*Juent ; Avhen the patient com- plains of Aveakness, and feels a desire for something to support his strength ; although these symptoms do not go so far as to indi- cate danger, the exhibition of wine is proper. The quantity must be proportioned to the urgency of the symptoms and the habits of the patient, but ahvays sufficient to remove this sense of debility. Dr. Moore erred in not having recourse to the wine till the more alarming symptoms shewed themselves. " When that prostration of strength so often mentioned hasta- " ken place, and is followed by stupor, low delirium, tvvitching " ol" the tendons, and other symptoms ; however proper Ave may " think the bark Avould be, ancl however eager Ave are to give it, '• this is no longer in our power. In this state the patient gene- " rally rejects it in all its forms, or will only take it in such small " quantity as can be of no service. Yet the case is not entirely "hopeless; for even in this situation, if the lips are moistened " Aviih a little warm wine, sweetened with sugar, he will shew a " relish for it; and when given in spoonfuls will-suck it into his '■ mouth with signs of satisfaction, after rejecting every medicine " with disgust, and refusing every other kind of nourishment " av hate ver, " In one particular case of this nature, which I well remem- " ber, after a certain quantity of wine, perhaps near a pint, had " h en given hi the' space of an hour, I perceived the patient's " pulse acquire strength ancl become slower, while the insensi- " bility seemed to wepr gradually away ; but the relations taking <; alarm at this quantity Of wine, notwithstanding these flattering «* appearances, withheld it. ancl offered the patient some other " kind of drink, which in their opinion was more suitable to hi? '• case, notwithstanding his again and again rejecting every thing " they offered. It was not till after they plainly perceived the " pn.se begin to sink, and the delirium to return, that they could " be prevailed on to give more wine, which on my returning to '• visit the patient, I persuaded them to do, and with the same " success as before. « I have known instances also Avhere the physician, not being " convinced that the filling of the pulse and the removal of de- " iirium was owing to the wine, has set aside the use of it in the « sume manner, till the return of the bad symptoms obliged him " to resume it, not without remorse for having made an expert « ment which had like to have proved fatal to the patient. CONTINUED FEVERS, 269 •" It is generally necessary in such cases to begin by giv- " ing the Avine warm with sugar, to induce the patient to " take three or four spoonfuls, but afterwards he takes it free- u ly cold and Avithout sugar. The reader might be astonish- " ed were I to mention the quantity of wine I have known some " patients take in this fever ; and in some cases of the confluent " small-pox, Avhere the weakness, insensibility, and other :ymp- " toms were the same, and where the recovery of the patient was u evidently owing to that cordial alone.* u The proper rule is to give tlie wine till the pulse fills, the *' delirium abates, and a greater degree of warmth returns to the M extremities. Upon the smallest appearance of the stupor com- tlie day ; and in one instance tiie patient took two bottles of Port i.i Lttle more than half that time. t More than twice this quantity of claret has been taken in 24 hours in the more alarming forms of typhus by people unaccustomed to the use of Avine with the best effects, and without the least symptom of intoxica- tion j so insensible is the system in a state of atony to the most powerful stimuli which tend to correct the atony ; whereas, by a moderate appli- cation of many of the natural agents, which acting now as atci.ick, ir.- trcasc the morbid state, life itself may be extinguhi-.c J.- 270 CONTINUED FEVERS. ° pulse becoming weaker," Dr. Moore continues, " or any other " symptoms returning, Ave must again have recourse to the Avine, " persevering in that quantity which is found by attentive obser- a vation sufficient to keep up the pulse, and Avard off the other bad " symptoms. When that quantity has been continued for several " days, it may be gradually diminished ; a little bread soaked in " the wine, or some other simple nourishment may be offered." Wine should always be conjoined with some farinaceous matter when the stomach will bear it, by Avhich the nourishment afforded is increased, and^as appears form a variety of facts relating to di- gestion, the wine itself better assimilated.* In extreme cases, hoAvever, where the digestive powers are "almost wholly suspend- ed, the farinaceous matter must be omitted, as it will then only occasion oppression, and may produce a disgust for the wine. As soon, however, as a remission ofthe symptoms is procured, sago, panada, or some other farinaceous matter, should be mixed with it. " After the patient is able to take panada mixed with wine " or bread soaked in it, Avith any degree of relish, the appetite " sometimes becomes very keen, and he is even willing to take " more panada, rice, or sago, mixed with wine, than is proper for ■" him. This return of appetite is undoubtedly one of the " strongest indications of returning health, but it must be indul- " ged with caution, the patient must be alloAved to eat but little at " a -time even of this kind of nourishment, and to return very " gradually to his usual food.t " Soon after the fever is entirely removed, and long before the * Fluids in general are but ill digested if not conjoined with some so- lid matter. I have known from experience that the strongest decoction of beef will not afford proper nourishment: but conjoined Avith any solid matter, although the latter affords little or no nourishment, it proves suf- ficiently nutritious. f There are few cautions which deserve more attention than this, par- ticularly with respect to animal food. " Even after the disease," Dr. Fordyce observes, " has been terminated by a crisis, animal food in a so; " lid state should be rejected, there being no cause Avhich has pro-" " duced reSapses, as far as the author's experience has gone, so freqjuent- " ly as using solid animal food too soon. Supposing even that a complete " -crisis should have taken place, and entirely terminated the disease, it " ought to be at least five or six days before any solid animal food is veu- *' tured upon. " The author wishes to press this more strongly, because if a perfect " crisis should take place, the appetite often returns, and the patient is " left in a very weak state. It has in this case been often conceived by the «* patient, and much more frequentiy by the by-standers, that solid annual " food would restore his strength soon.' It must however be remembered, " that Avhen a complete crisis takes place, and carries off the fever entire- " ly, the depression of strength, which was a symptom of the fever, ceases, *' and the weakness which was produced by the exertions and derange- " mentof the faculties ofthe system, is no longer increasing; and that the " patient with very moderate nourishment and the sleep and rest which " are so apt to ensue after the fever has been completely earned off, will A Jaave his strength restored in a very short time, without using any tiling ■" that shall run any risk of reproducing the disease. CONTINUED FEVERS. 271 c< patient has recovered his strength, he will by proper manage- " ment be entirely Aveaned from the wine ; or his allowance may " be reduced to two or three glasses in a day, if the physician " should think that quantity more proper than none." This part of Dr. Moore's observations is also exceptionable. We should not discontinue the wine when the febrile symptoms are remo- ved, but Avhen the patient is restored to health. Wine is not only the most poAverful means of correcting the atony, but the best article of diet for removing the debility which succeeds it. After the removal of the fever indeed the quantity must be great- ly diminished ; it must never be sufficient to produce the least symptom of intoxication ; a feAv glasses in the day will in gen- eral be found sufficient. " Indeed the third part of what formerly " had proved a salutary cordial ancl a restorative,' would in this " state of convalescence occasion a dangerous state of intoxication. " So great a difference is there in the effect of this cordial upon " the constitution in this state of extreme weakness, when all the " natural functions seem loaded and clogged by disease, from * what it has in perfect health, or when the fever being just re- •' moved, the animal functions gradually resume their former u course. " Claret is the Avine I have generally recommended, when the " circumstances of the patient Avould afford it. I have seen the " same good effects hoAvever from the use of Port, Madeira, " ancl other wines. And when no kind of Avine is to be had, " brandy or rum diluted Avith Avater or milk, and sweetened with " sugar, must be substituted in its place. « In the state of stupor, debility, and Ioav delirium, already de- " scribed, spirits diluted have nearly the same effect with wine, M and are even more relished by a certain class of patients." We should never have recourse to distilled spirits except where wine cannot be procured. Many practitioners fall into a serious error who believe that provided the same quantity of alcohol is exhibited in typhus, it is of little consequence in Avhat form it is given. Porter, and the other fermented liquors of this country, which have not been distilled, are preferable to spirits, (especially if the patient has been accustomed to them) when the digestive powers are not extremely weakened. In the more alarming forms of typhus they occasion oppression and disgust. But although dis- tilled spirits be found necessary in the height of the disease, to- wards its decline, when the appetite begins to return, and espe- cially after the fever is removed, and our view is merely to re- store the strength, any fermented liquor, which has not been dis- tilled, provided it does not disagree with the stomach, is prefera- ble to those which have. Numberless observations have rendered it certain, that both the more immodiute ancl permanent effects »f distilled spirits, •S7& CONTINUED FEVERS. are very different from those of other fermented liquors. I knovr people who cannot take a small quantity of spirits, though much diluted, without experiencing the debilitating effects of it for se- veral days -r yet they can drink a much larger quantity of alcohol, in the form of wine or beer without inconvenience. The most violent fit of dyspepsia I ever saw, which continued for several •weeks, was induced by tAvo small glasses of spirits, taken to re- move the cramp in the stomach. Let any one compare the state of those who indulge in the ex- cessive use of wine, or the undistilled fermented liquors of this country, vtith that of the habitual dram drinker. The former are plethoric, lusty, and often vigorous ; the latter, meagre and palsified. This difference is often striking between drunkards among the loAver ranks in England, whose liquor is porter or strong beer, and those among the same class of people in many parts of Scotland, where they drink a spirit distilled from malt. We have reason to believe, that the pernicious effects of distil- led spirits are to be ascribed to the alcohol being separated from the miider particles Avhich sheath it in wine and beer, and pre- vent it from exerting so hurtful a stimulus on the animal solid. The hurtful effects of this stimulus, is lessened by dilution, but no dilution will reduce the alcohol to the state in which it was be- fore distillation. We bring it as nearly as possible to this state by the addition of some mucilaginous matter. Punch therefore with a due proportion of sugar, is the form in which distilled spi- rits are least hurtful, ancl that in which they should be given to febrile patients. If the sweetness of the sugar occasion disgust, any other mucilaginous matter may be used in its stead. Popu- lar habits are always the result of extensive experience, and much information may often be acquired by an attention to them. In those countries where distilled spirits are generally used, punch is the form in which they are taken, except by drunkards, who require the stimulus of the pure spirits. In punch all the means of obviating the hurtful effects of spirits are combined ; they arc diluted with a large proportion of water, sheathed by the mucila- ginous quality ofthe sugar, and their stimulating power is dimi- nished by the addition of an acid. With all this preparation however the use of distilled spirits - never produces the same strength and vigour which wine or beer do. Wine seems preferable to beer only from its being less apt to clog the digestive organs. Of all wines good dare? is perhaps tne best in typhus ; there the alcohol is neither too much diluted, as in small beer, which hardly possesses any of its inviKoratintr property; nor too much concentrated, as in the stronger wines, whose effects approach to those of distilled spirits. Port v ine diluted with nearly an equal bulk of water is a good substitute for claret. When the vvme drank was port I have repeatedly seen much advantage in diseases of debility from diluting it. CONTINUED FEVERS. 273 The vitriolic ether has lately been employed in typhus, with the same vieAV as wine ; the reader wiil find it particularly re- commended by Dr. Smith, Dr. Chisholm, and others. Its effects are similar to those of wine, but it is much less to be depended upon. Dr. Smith thinks it particularly useful joined with anti- monials. Employed in this Avay it often proves a powerful dia- phoretic, and is chiefly indicated when the symptoms of typhus shew themselves at an early period. It is evident from what has been said, that no quantity of wine can be mentioned as forming a proper dose in typhus; the quan- tity must at all times be regulated by the state of the symptoms, and the change which^the wine induces. It particularly deserves attention, that Ave are not to be deterred from the use of Avine in typhus, although the ^delirium run high, resembling that which occurs in the synocha; for even in these cases it is found to remove the delirium, while it lessens the fre- quency and increases the strength of the pulse. Dr. Walker, in his Treatise on Small-I'ox, observes, that he has seen a young man in typhus, so furious, notwithstanding the pulse being weak and frequent, that he could scarcely be kept in bed by tAvo strong men, immediately quieted by wine. I have heard an excellent practitioner confess, that in such a case he has hesitated whether to let blood oivgive a large dose of opium ; he adopted the latter plan, which was followed by the best effects. , Next to wine, and other fermented liquors, the bark is found the most successful medicine in typhus. In most cases of this fever, however, it is in several respects inferior to wine. Wine Ave know is a poAverful stimulus both to the nervous and muscular system. It is also a nourishing article of diet; it is re- ceived into, and at least in part assimilated Avith, the fluids ofthe body. The bark, on the other hand, affords no nourishment; and it is even probable, from several observations related whe«i speaking of intermitting fever, that it is either not received into the mass of blood, or although in part received, its effects aro chiefly to be attributed to its action en the stomach and intestines. On the muscular fibre the bark seems to exert but little power; the immediate action of this stimulus appears to be on the nerv- ous matter, through which its invigorating effects are diffused to other parts ofthe system. In those cases of typhus, where there is a tendency to sponta- neous gangrene, the'bark, if it can be taken in large quantity, is periiaps a more powerful medicine than wine, but both conjoined are preferable to either alone. In other cases it is inferior to wine ; but AvhcreA'er there is a considerable degree of debility, if tl.s stomach can bear it, it forms an useful addition to the wine, and may be given in extract or infusion, with a few drops of sul- Vol. I. ■ LI £74 CONTINUED FEVERS. phuric acid, if the stomach will not bear the powder, in Avhich form it is ahvays most effectual. Most of the authors I have had occasion to mention used the bark in fevers Avith more freedom than wine. De Haen gave an ounce of the extract daily in malignant fevers; and in the first volume of "his Ratio Medendi, relates cases to prove its efficacy. Huxham gave it in decoction with aromatics ancl a small quantity of distilled spirits ; and Hasenohrl is one of its strongest advocates. " Supervacaneum quidem est," he observes," aliquid addere quod " egregiam corticis Peruvian! virtutem in febribus admodum nu« " lignis demonstret."* . We found when speaking of intermittents that Avherever the in- flammatory diathesis is considerable, blood-letting is necessary previous to the exhibition of the bark. Some practitioners, it Avas observed, losing sight of the circumstances which gave rise to this practice, seem to regard venesection previous to the exhibition of, the bark as necessary in all cases. This prejudice has even been transferred to the treatment of continued fever, in consequence of which blood-letting has somtimes been employed in circumstances the most improper. Dr. Cullen justly remarks, in his Materia Medica, -hat wherever blood-letting is proper in continued fever, the bark is universally prejudicial. But the prejudice that has chiefly opposed the use of the bark in continued fever, and which also originates from the practice found most successful in agues, is that this medicine will not suc- ceed unless the remissions be evident. " I can also affirm from " experience," Dr. Grant observes, "that the bark will not succeed " unless the fever has adopted the type of an intermittent, and " then the danger is nearly over if it is suffered to take its course." This observation is just if it be confined to those fevers in which the symptoms peculiar to synocha prevail ; but in typhus the continued form of the disease is no objection to the exhibition of ^e bark. When speaking of the treatment in agues it was shctvn, from the observations of different practitioners, that, although Avhere- ever any degree of the inflammatory diathesis prevails the bark is onlv to be exhibited in the absence of fever, and wherever this diathesis is considerable*it is to be delayed altogether, till the inflammatory state is removed by proper remedies ; yet in all cases Avhere the debility is considerable, the shortness and incom- pleteness of the remissions only indicate the necessity of using the ba.k more freely, and that after the fever in such cases has assumccUthe continued form, the bark is still to be exhibited in smaller doses. * See Ilasenriirl'sHistoria Febris Petechialis. The rtader will alss fird cr.ses in this Treatise demonstrating the benefit arising from the m of ty- phus; besides, it has just been observed, that tonic medicines are sometimes the principal means of checking such sweats, and in this way they are always useful after the typhus has commence 1; the sweating being often protracted by the debility it occasions. Opium however, from its tendency to promote perspiration, should be avoided. Tralles, in his work on opium, alleges that the mi- liary eruption may often be induced by the use of this medicine. As the appearance of miliary eruption in continued feA'er ren- ders the tonic plan more necessary, it follows as a consequence that it renders the opposite plan more pernicious. The bad ef- fects of blood-letting and much purging in the miliary fever hwe often been observed; and they arc ranked by the generality of authors among tlie principal causes of retrocession. Without attending to the antiquated theories of repelled erup- tion, of this we are assured, that Avhatever debilitates, in most cases of miliary fever, is pernicious; whatever supports the vigour of the system, beneficial. It is not to be overlooked hoAvever that there are cases, where notwithstanding the sweatings and miliary eruption, the excitement is such as in all kinds of fever warrants blood-letting. Jn these-cases the theory of retrocession deserves as little attention as in the former. In the one case we avoid blood-let- tin j, because the excitement is already sufficiently Ioav ; in the other we employ it, because the excitement is such that its continuance would occasion a greater degree of debility than the blood-letting Avhich relieves it; nor, reflecting on Avhat has been said, need we fear that blood-letting in such circumstances will repel the erup- tion. It is determined by experience, says Burserius, that if while the miliary eruption is present, an inflammation ofthe viscera be feared, or if the fever be very vehement, a large blood-letting may be employed without repelling the eruption. Quarin and others make similar observations. Blood-letting, says Quarin, is parti- cularly necessary in the miliary feA'er, when it has arisen from the abuse of spirituous liquors, or the suppression of the lochia, that is, he might have added, where the excitcnic.it runs high. In such cases, however, the evacuation sluirid be less in propor- tion to the excitement than in cases of simple synochus. Reviewing all that has been said we shall find, that the change which the appearance of the miliary eruption and the symptoms that .wteiid it render proper in the treatment of synochus, consists in employing tonic rei.ic.iies more liberally, and evacuations more sparingly, than in cases unattended by an eruption ; the miliary eruption tending constantly to overcome excitement and produce debility. The nature of the complaint thus leads to the practice Avhich experience has proved to be most successful.* * Li considering the treatment <_i the synochus miliaris I have taken no 303 APHTHOUS FEVER. The remedies which hove been employed, when a retrocession of the eruption, attended by various symptoms of debility, hap- pens, are the same as those'recommended in similar circumstan- ces in other eruptive fevers, ancl which vve shall presently have occasion to consider more at length. In the disca*e before us, musk and camphire are particularly recommended where convul- sions supervene ; opium, blisters, ancl frictions of the skin, in an cases. But our principal vieAV should be to bring out and support a sweat, and if the retrocession be followed by any considerable evacuation, wc must be careful not to check it. Different means, it is evident, will be proper in different cases, according to tho cause of the retrocession.* See Avhat has been said of the cauv es of retrocession^ SECT. IIL Of the Aphthous Fever. THE Aphthous Fever is defined by Dr. Cullen, "Synochus.' Lingua lumidiuscula, lingux et faucium color " purpurascens ; ascharss in faucibus, et ad lingux margincs, " primum comparentes, os internum tolum demum occupantes, " albidx, aliquando discretae, sxpe coalesccntes, abrassc cito re- " nascentes, etincerto tempore manentcs." This definition, we shall find, does not include all the affections •which have been knoAvn by the name of aphthae ; but it describes with sufficient accuracy that to which, by the general consent of physicians, the term is now confined; It appears from what was said in the introduction, that the aph- thous fever is to be regarded irt the same point of view as the. miliary, bcinc; nothing more than the common synochus accom- panied with an eruption of aphthx, and the peculiar symptoms that attend it, whether accompanying fever or other diseases, or appearing as an idiopathic affection. In detailing the symptoms of the synochus aphthosus, I shall pursue the r.jmc method followed in detailing those of the syno- chus miliaris ; in the first place giving an account of the erup- tion, then ei':iii"jicruting the symptoms Avhich precede or attend it, nnd lasjtly pointing out the febrile states in which k is most apt to shew iuelf. notice of blisters, Avliich haA'e been warmly recommended in this fever, as there is nothing to be added en this part cf the subject to what was said in speaking of the treatment in the synochus simplex. It appears from what was then said, that their cordial property, for which the) accm chiefly to have been recommended in the miliary fever, is very inconsiderable. * Quarin thinks that tlie retrocession is the more dangerous tlie more cr.pijus the eruption. APHTHOUS FEVER. SOI \. Of the Symptoms of the Aphthous Fever. Of the Aphthous Eruption. The aphthae infantum* is the same eruption which occasionally appears in synochus ; and whether it attacks the infant or the adult, and whether it appears with or without fever, it is attended wih the same train of symptoms. Asa symptom of synochus it has not demanded so much attention as where it appears as an idiopa- thic affection, Avhich it seldom does in adults. In the writings of those who treat of the aphthx infantum therefore Ave find the best account of this eruption. I shall describe the idiopathic affection as it appears in children, and then shew that all the symptoms of aphthae infantum occasionally attend this eruption when it shews itself in synochus. The local affection of the fauces is often the first symptom of the aphthx infantum ; certain symptoms however now and then precede it even in the youngest children. From appearing in health they sometimes, very suddenly, shew signs of uneasiness ; they either refuse the breast, or if they receive the nipple, do not suck ; they appear restless and anxious, cry much, sleep Ics3 than usual, ancl what sleep they have, is disturbed. They be- come pale and emaciated, and are often troubled with hiccup, and diarrhoea in which the stools are acrid ancl fetid. Curdled milk is sometimes past by stool, and bile evacuated by vomiting.t Such arc the symptoms which Ai•ncm.uv.i says he frequently observed to precede the appearance of aphthx.J They are sometimes preceded by other symptoms. If the child is not very young, the pulse is often considerably affected, becoming more frequent than in health, the temperature is in- creased, and a sleepiness sometimes approaching to coma super- vene-. Upon the Avhole however, in children, the affection of the mouth and fauces is generally the first symptom, the mouth becomes redder than natural, the tongue swelled and rough, and the nurse perceives an increase of temperature in the child's mouth. Sometimes the mouth becomes pale instead of red pre- vious to the eruption of aphthx, which generally presages a Avorse form of the complaint. Soon after these appearances, the aphthx begin to shew them- selves in the internal faucca, and about the edges of the tongue. " Pusttilx sunt albicantcs," says Kctelacr,|J who saw as many ca- * Tlie thrash. X Arnemann's Commcntatio de Aphthis. tit will appear, as we proceed in considering the symptoms cf this complaint, that thos-c- here enumerated bv Arm-mam ■. as hwpieatly prece- ding the affection ofthe fauces, arise from the aphthous eruption hrst seizing upon the crsophagus. U Tv.-tda'.-r's'T-.a-ativj de Aphthis Nostratibus. S02 APHTHOUS FEVER. ses of this disease as perhaps any other practitioner, " sum mis " ac internis oris, et interdum vicinis rcspirationis partibus insi- * dentes." The true aphthx are described in nearly the same manner by most authors avIio practised in those countries Avhere the disease is common. Armstrong compares their first appear- ance to that of broken curds. Even on their first coming out, aphthx sometimes so run to- gether that they look like a white compact crust, covering a great part of the internal fauces, and often arising as it Ave re from the oesophagus. At first, Boerhaave* observes, solitary pillules of- ten appear here and there on the tongue, angles ofthe mouth, fauces, and neighbouring parts ; these are generally of a favoura- ble kind. Sometimes they appear first in the deepest part of the fauces, as if ascending from the oesophagus, in the form of a Avhiie dense shining crustf gradually spreading over the fauces. These are of a bad kind and generally fatal. Boerhaave adds another appearance which they sometimes assume, " A'liquando duns " crassis densis tenacibus crustis, totum jcavum oris ubique, us- " que ad labia obsident, omnia tegentes simul: et ab his rarore- " surgent segri." » In short, aphthae are small whitish eschars, appearing in the fauces and about the tongue or lips, sometimes few and distinct, at other times numerous and confluent. Their number am: de- grce of confluence are particularly to be attended to, as the prog- nosis rests much upon them. In determining the number of aphthx we may sometimes he deceived, since they are often numerous on the deeper seated parts, wl>ile they are but thinly scattered on the tongue and other parts of the mouth. It also happens, though rarely, V in'Jwietcn observes, that although there be few aphthx on every p:,:t which can be seen, yet on the more internal parts (for Ave shall find that the seat of aphthx extends much farther than the fauces) they are very numerous, and may often therefore prove fatal avIvj., tiie physician least expects it, if he forms his judgment from the ap- pearance of the fauces alone. But even in this case, a person acquainted Avith the nature of the disease can hardly be mistaken, for wherever the aphthae are numerous in inter, .a! parts, sickness, hiccup, oppresdon, and generally pain rei'cired to the stomach,, Avith much debility, point out the chnger, v iri tii when these symptct >.s occur is always ur- gent, Avhatever be ♦he state of the fauces. The presence of this variety of the disease, it is evident, is not so easily ascertain- ed in chileicn as in i-.duks. Whatever be the attending symp- toms, however, when the crust mentioned by Boerhaave, appears to ascend from the oesophagus, it is probable that the moreinter- * Aph. 984. t It i, in this case that the symptoms mentioned by Arncinann most fre- quently precede the appearance of Aphthx, APHTHOUS FEVER. 503 fial parts are considerably affected, and the prognosis therefore is bad. Nor is the case more favourable Avhen the whole mouth appears covered with a crust and becomes dry, the process which ought to throw off this crust being absent or extremely languid: If this state of the fauces continues for a considerable length of tiniT*, the power of SAvailovring is lost, and the danger becomes very uv^ent. Van Swieten met Avith cases of this kind in which the tongue, lips, and cheeks \vere rendered almost rigid by the crust ; so that a -liquid could not even be retained in the mouth ; at length, he observes, the same complaint spreading to the fau- ces, the patients were suffocated. The colour cf the aphthx has occasioned some dispute, which seems to he vc arisen from the same aphthx changing their colour and beam,ing darker the longer they adhere ; for there seem to be no well authenticated crsc, in which the aphthx. on their first appearance Avere of a dark brown or black colour, as some writers have alleged. Boerhaave indeed observes, that the colour of aphthx is various, being either of a pellucid or shining white, like pearls, or of an opaque white or yellow colour, livid, or even black.* But Boerhaave speaks here not of the difference of aphthx on their cor ring out, l>n<. of the appearance of the same aphthae at different periods ; for his commentator Van Swieten, Arnemann, Ketel ;er, Armstrong, and others, who had extensive opportunities of seeing this c'heavj, declare that they never saw aphthae dark red, brown, or black on their first appearance. " Non enim veri- u simile est," Kctciaer observes, " utin rebus sibi adeo vicinis, et " cognatis, fbrs tantum polleat, cum albae plus millies nobis obla- M tae sint, ut rnbrvrurn, nigrarumve, ne umbrae quidem unquam .*' apparuerint." Vve therefore sec the propriety of Dr. Cullen's making a* hiteness one of the distinguishing marks of this erup- tion ; and giving it a place in the nosological character. But although aphthx on their first appearance are never of a dark broivn or black, they sometimes, though not very frequently, appear of a light brown or ash coioiir. Arnemann terms the co- lour of these '• flava vel-fuscae cineritix." The white pellucid'aphthx, like pearls, are always the safest,! and when they are few in number the disease i'- scarcely attended with any danger; but Avhen ephihx appear from the first of a brownish colour, the prognosis is verv bad. Van Swieten says, that he has uniformly found such cases fatal. The prognosis is between these extremes; when the aphthx appear at first of a pearl colour but in considerable number, and soon begin to assume a brownish hue ; when they become black the danger is very ur- gent ; they are then to be considered as nothing less than small * Aph. 9:5. t When they appear of an opaque white, like lard, they are less fa- vourable. 304 APHTHOUS FEVER. gangrenous sloughs, a\ hich often reduce the Avhole internal fauces to a state of mortification. It has just been observed that it is only after the aphthx have remained fcr a considerable time that they become brown or • black; henrc the time they adhere becomes a point of conse- quence in forming the prognosis; but when they begin to fall, we shall often be deceived if we look for the immediate termina- tion of the disease, since it frequently happens, that a fresh crop succeeds that which has fallen or been rubbed off. •i If this crop appears more numerous and croAvdcd together tiwn the fii"-t crop, the prognosis is Avorse than when the aphthx ap- pear fewer and more distinct. But upon the whole one crop fall- ing off and another appearing affords a more favourable prognosis, than one crop continuing for the same space of time, and becom- ing brown or black, which is always indeed the effect of its colli tinuance. Aphthae sometimes fall off in the space of ten or twelve hours, at other times they remain attached for many days; nor do thev fall from the whole fauces at the same time, nor always first from any one part, but in this respect they are as variable as in their duration. Although when the disease continues for a considerable time, repeated crops of apthae afford a more favourable prognosis than the same crop remaining throughout the whele course of the dis-s ease ; yet the prognosis is still better, when the aphthae fall early, as in the former case, ancl are not succeeded by a fresh crop or on- ly by a very scanty one ; it is therefore a matter of much conse- quence in forming the prognosis to be able to foresee whether or not a fresh crop of aphthx is about to come out, and this in some measure may be learnt from the appearance of the places avIucu' the former occupied. If they be clean, red, and moist, the aphthx either do not re« appear, or only reappear in a small number ; but if the parts the first crop occupied appear foul ancl parched, then we "may'very certainly except a renewal of the eruption, and in such cases the separation and reproduction of tlie aphthx often take place a great number of time: before the final solution ofthe disease/ Both Ketelaer and Van Swieten observed this process repeated to/ the sixth, seventh, or eigluh lime ; and the latter remarks that he has sometimes known an interval of- several days betAveen the separation and reproduction of the aphthx; but. upon the whole, however frequently they return, those aphthx which fail off the soonest are the safest, There are two seemingly opposite extremes, which are noAV ancl then equally dangerous. The one when the iicav crop" super- venes before the old crop is thrown off ; this not caly. -rives risj to a great number of aphtha; adhering at the :...:r.e time, but ai$a APHTHOUS FEVER. 103 shews that they have little tendency to separate, which is always an unfavourable sign* * The other, and no less dangerous, case is when the first crop falls off, and from the appearance of the fau- ces we are led to expect another, Avhich however does not come out, or, at least, is delayed for some days. If, along with this symptom, much anxiety, oppression, and other marks of debility, or a degree of coma, supervene, the danger is very considerable, this case generally proving fatal if a fresh crop of aphthae do not make their appearance, which in most instances is attended with relief. In the most favourable cases then, the aphthx appear of a white pearly colour, fall off early, leaving the places they occu- pied clean, red, and moist ; and upon the separation taking place, all the symptoms begin to abate, ancl in a short time wholly dis- appear. On the other hand, the more the aphthae assume a broAvnish tint, the longer they continue to adhere, the more foul and parched the places which they occupied appear, the sooner the first crop is succeeded by another, or the more alarming the symptoms of debility or the coma when a second crop does not make its appearance, the greater is the danger. We have hitherto considered the course of aphthae in the fau- ces, where it may be seen, but this disease sometimes extends to the more internal parts, ancl seems to run the same course in them as in the fauces. " Lathis quandoque propagantur aph- " thae," Lieutaud* observes, " qux oesophagum, ventriculum et " intestina haud sine presenti viiae discrimine nonnunquam inva- " dunt." The same observations hayc been made by all who have been conversant in this disease. The symptoms which indicate that the disease has extended to the stomach ancl alimentary canal, are various. Many of these however cannot be detected in the aphthat infantum, since infants cannot describe what they feel. In treating their complaints we must trust to our OAvnobservation and that of the attendants. The symptoms to be discovered in this way, and Avhich teach us that the complaint is extending along the alimentary canal,, are, an appearance of much anxiety, oppression, and debility, vo- miting, hiccupt, what Armstrong calls watery gripes,^ and con- vulsions. What places the matter beyond a doubt is finding aph- thae about the time they are observed to separate in the fauces,. thrown up from the stomach, or passed by stool. Ketelaer saw them thrown out in both ways in astonishing * Synopsis Med. Pract. f Hiccup attends aphthx in the oesophagus or stomach. See Van Swie- tcn's Commentary on tiie '659 Aph. of Boerhaave. X This is one of the most fatal symptoms, as we shall see more particu- larly in considering the treatment in this complaint, which must be se regulated as carefully to prevent the appearance of this tvniptom. Vol. I. P p 20« APHTHOUS FEVER. quantity. « Aphtiias quando jam maturuerunt et excernuntuf, " tanta copia aliquos dies per os etper alvinn nonnunquam rcjicf, " ut aliquot pelves vel inatulx congestas eas vix capiant." Vogel makes a similar observation. This is almost incredible, and de- notes the very worst form of the disease. Were there nothing to destroy the patient but the debility which so profuse an evacua- tion must occasion, he could not long support it. Aphthae have also been found in the trachea extending, as Lieu- taud* observes, eA'en to the bronchia:. They are knoAvn to have extended ta the trachea, and bronchix by the presence of dyspnoea. and by their being thrown up by coughing. This is perhaps the most dangerous form of the disease, the aphthx often accumula- ting in the wmd-pipe or its branches so as to occasion suffocation. Besides the symptoms which have been enumerated, there are others, Avhich, though less essential, often accompany this disease. When the aphthx of the mouth fall off, a salivation often ensucsy in part r.t least caused by the high degree of sensibility which re- mains, the whole internal fauces sometimes appearing as if the cuticle had been abraded. About the same time also, a diarrhoea frequently supervenes, which may cither be produced by the affection of the stomach and the intestines themselves, if the disease has extended to them, or by ihe acrid matter secreted in the mouth being swal- lowed. As these symptoms supervene towards the termination of the disease, when the patient is much debilitated, they often prove alarming, sometimes carrying him off when the attendants, and even the physician, judge the danger nearly passed. When tffese discharges are moderate, they have been looked upon as salutary. This opinion, however, is as much perhapsao inference from hypothesis as from facts ; it being a favourite maxim with the older physicians, that the dregs of the fever, at they Avere termed, should be carried off by catharsis or venesec- tion. The patient indeed often recovers about the time the sali- vation and diarrhoea appear. But at this period the aphthx fall, and the complaint generally remits, whether such symptoms stir pcrvene or not. It will appear however in considering the treatment, that a mod- erate diarrhoea at the time the aphthae fall is often useful, espe- cially when the disease has spread to the stomach and bowels, by preventing a relapse, which the irritation of the fallen aphthae in the bowels frequently occasions. The taste in general is nearly lost, and deglutition is often pre- vented while the aphthous incrustation remains.. -After it is se- parated, on the contrary, the taste is so acute, and the whole inter- pal fauces so sensible, that the mildest food gives pain, and the * Synopsi Med. Pract. APHTHOUS FEVER. sor jafient is now, although from a different cause, often as incapable «jf SAvalloAving as before. The aphthae indeed frequently leave the parts so sensible, that they bleed on the slightest occasion ; hence it is that bloody saliva and bloody stools frequently attend this disease. Boerhaave justly observes, that if Ave reflect that the seat of aphthx is in the stomach and intestines, as Avell as in the fauces, Ave shall not be surprised at the variety of symptoms Avhich attend, or folloAV them. This indeed readily explains the greater part of these symptoms, bloody or dysenteric purging, symptoms denoting inflammation, excori- ation, or mortification, in the alimentary canal. " Aphthx igiiur " vulgatiores et ori coercitx," says Lieutaud,* " mini me sunt " pertimescendx, et facile evincuntur, sed ubi oesophago infigur.- **-tur, ad ventriculum et intestina se spargere solent, hinc subori- w untur febris, tormina, diarrhoea, dysenteria, aliique graviores " morbi: si vero laryngem subeant, et ad tracheam bronchia et *' pulmonesdiffundantur; tussem ferocem, spirandi difticultatem, u alique truculentiora symptomata concitant." Notwithstanding what Lieutaud says in the first part of this quotation, aphthx, even when they extend no further than the fau- ces, are often a very alarming disease. For besides proving dan- gerous in the ways already mentioned by impeding deglutition and tending to interrupt respiration, even where the disease has not spread to the trachea,t aphthx often induce mortification on the palate and neighbouring parts ; for it frequently happens that when the aphthx adhere longer than usual, the parts beneath be- come gangrenous, and the mortification sometimes extends to the palate bones.}: The aphthx infantum are sometimes complicafetPwith other diseases, most frequently with worms. Such are the symptems of idiopathic aphthx, the aphthx in- fantum. Idiopathic cases of aphthx rarely occur in adults. Kc- lelaer indeed declares that such cases are very common ; but it was observed iu the Introduction that Boerhaave had seen but two cases of this kind, that neither Van Swieten nor Cullen had seen one, and Arnemann very few. Vv hen aphthx appear as an idiopathic affection in adults, the symptoms do not'differ tio-n those of the aphthx infantum, and the treatment in both cases is the same. Of the Symptoms preceding and accompanying Aphtha. Although the complaints in which the miliary eruption occurs, arc no less various than those occasionally attended by aphibs, yet it appears from what Avas said of the former eruption, that in * Synopsis Med. Pract. t Aphthx, Vogel observes, often occasion suffocation merely by the swelling of die fauces which attends them. X Aph. Boerhaavii, Aph. 989. >3oa APHTHOUS FEVER. whatever complaint it appears, a certain train of symptoms.ge- nerally attends it. The same is true of aphtha:, although the ac- companying symptoms in this instance are less uniformly pre- sent. When aphthx begin in internal parts (which is sometimes the case in the symptomatic as well as idiopathic aphthx) their ap- pearance in the fauces is consequently preceded by the varioui symptoms denoting their presence in other parts of the alimentary canal. In this case the aphthx appear to ascend from the oeso- phagus in the same manner as in the worst cases of aphthx in- fantum. Anxiety, oppression, and debility however often precede the appearance of aphthx, when they are about to make their first attack on the fauces, and like most other'eruptions, they are now and then preceded by a degree of coma, less frequently by deli- rium. But such symptoms frequently occur in fevers where no aph- thx are about to appear, and aphthx sometimes appear without being preceded by these, or indeed any other symptoms, which can be supposed particularly connected with their appearance j so that although there are certain symptoms which frequently precede this eruption, especially when it begins in internal parts, yet there are none from which we can with much certainty pre- dict its appearance. If hoAvever the foregoing symptoms occur in fever, while at the same time the fauces appear unusually red or pale, there is reason to expect an eruption of aphthx. It is almost unnecessary to observe, that when aphthx spread from the fauces along the alimentary canal, they, are followed by the same symptoms Avhich precede their appearance, when they make their first attack on internal parts. " But of much more " uncertain and dangerous event," Huxham observes, speaking cf malignant fevers, " are the brown dark coloured aphthx. Nor " are those Avhich are exceedingly white and thick, like lard, of a " very promising aspect; they are soon succeeded by great diffi- " culty of SAvallowing, pain and ulceration of the fauces, cesopna- " gus, &c. and Avith an incessant singultus; the Avhole primx vix " become at last affected ; and a bloody dysentery comes on fol- " lowed by a sphacelation ofthe intestines, as is evident from the " black sanious bloody stools, horribly fetid and extremely infec- " tious." ' Upon the whole, the symptoms ofthe symptomatic aphthx are not different from those of the aphthx infantum, except that the former generally occurring in adults, Ave have a more distinct ac count of many ofthe attending symptoms; and that these symp- toms are occasionally modified by the idiopathic disease in which the aphthx appear. APHTHOUS FEVER. 3,03 Of the Febrile States in which Aphtha most frequently appear. In some fevers there is a remarkable tendency to dysenteric af- fections. The symptoms of dysentery are afterwards to be Con- sidered ; it is sufficient at present to observe, that in fevers at- tended by much griping and mucous and bloody stools, the ap- pearance of aphthx is more frequent than in most others. The first mention of aphthae which occurs in the Avorks of Sydenham, is in his account of the dysenteric fever of the years 1669, 1670, 1671, and 1672. The aphthae generally supervened in those cases in which the fever proved obstinate, and chiefly, he observes, where the hot regimen had been pursued, and diarr- hoeas checked by the unseasonable use of astringents. " Prae- " sertim si, praetcr regimen calidius, evacuationes etiam per al- " vum medicamentis astringentibus prius fuerint coercitac." Ar- nemann makes the same observations. Sydenham further observes of this fever, in which aphthx Avere more frequent than he had found them in any other, that it Avas seldom or never attended Avith sweats, while in fevers, unaccom- panied by aphthx, the sweating Avas often profuse. The latter remark has been confirmed by many succeeding observations. Ketelacr even goes so far as to maintain, jhat it is the deficiency of perspiration that renders aphthx more frequent in cold than in warm climates ; and in support of this opinion he asserts, that he has found aphthx rendered milder by a copious floAV of sweat or urine, and that every thing tending to check these discharges, increases the virulence of the aphthx. Notwithstanding the truth of these observations, aphthx are apt to appear in the miliary fever, Avhere there is generally much sweating. There is such similarity between some of the symp- toms attending aphthx, and those attending the miliary eruption, that some have believed these eruptions to arise from the same cause,* and that when the appearance ofthe one is ji evented, that of the other, the general state of the symptoms remaining the same, is a necessary consequence ; and to this circumstance Van :Swieten thinks Ave may ascribe the frequent appearance of aph- thx in cold countries, where the flow of sweat, and consequently the appearance of the miliary eruption, is checked; and on the other hand, the frequency of the latter eruption, with the rarity of the other, in Avarmer climates. The frequent concurrence of the miliary eruption and aphthx, certainly points out some connection between the tv. o affections. Sydenham seldom met with aphthx in fevers, except in the one just mentioned, remarkable for its dysenteric tendency ; and in that which was mentioned when speaking of the synochus milia- ris, in which he frequently observed both eruptions. " In the * " Materiem aphthojjam et niiliarcm eamdem esse judicabam." Stoli's Ratio Medendi. Oio APHTHOUS FEVER. « course of many miliary fevers," says M'Bride,* " it is frequent " to see aphthx in the mouth and ulcerations in the fauces preying K upon the tonsils and uvula." This fact hoAvever does not certainly warrant the opinion, that both affections arise from a cause lurking in the body, that must produce the one eruption or the other. We are well assured that the miliary eruption may be prevented without inducing aphthae. It will appear more clearly from what will be said of the causes of aphthx, that irritation of the primae viae and skin, seems, from a well-knoAvn sympathy which subsists betAvecn the different parts of the alimentary canal, and betAvecn every part of it and the skin, often to give rise to this affection of the fauces, mid it is in this way that Ave may account for aphthx being so common in dysenteric fevers, and in those where the skin is un- usually parched, or covered with so irritating an eruption as the miliary. Aphthx are also most apt to shew themselves where the debil- ity is considerable ; and particularly when those symptoms, which have been termed putrescent, make their appearance. In adults, says Arnemann, aphthx very frequently follow putrid, continued, ancl intermitting fevers ; " prxcipue febres autur.inales, qux cum " diarrhcea et dysenteria incipiunt, imprimis si xgroti, calidore- " gimine fuissent usi, vel materix peccantis evacuatio adstringen- " tium usu intempestivo foret impedita." Francis, he adds, met t with aphthx in putrid continued fevers ; Bosch in putrid inter- mitting fevers ; Grant in the irregular quartan and tertian; Hil- lary in the malignant'dysentery ; Huxham in the low nervous fe- ver ; Sims in a similar fever ; Kloeckhoff in an epidemic contin- ued fever; Untzer in putrid and hectic fevers. Such are the fevers in which aphthx frequently appear. The characteristic marks of these fevers are morbid affections of the skin and bowels, and much debility. There are many other complaints, occasionally attended Avith this eruption, and as in fevers, so in these, it is still most apt to appear where debility prevails. Among the principal of these are worms and dysentery, further denoting the tendency of aph- thx to accompany affections of the alimentary canal; and scurvy, phthisis pulmonalis, and the last stage of all kinds of dropsy fur- ther denoting their tendency to appear in debilitated states of the system.f Such are the aphthx properly so called, the symptoms which'at- tfend them, and the fevers in Avhich they are inosti.pt to appear. The term aphthx however has been used to express complaints very different from the true aphthx. Most of these arc local af- * Introduction to the Theory and Practice of Medicine. t Boerhaave remarks, that aphthx are apt to accompany all visceral inflammations. APHTHOUS FEVER. Sit Sections of little consequence ; it will be sufficient to mention a few of the most remarkable. The indefinite use of the term aphthx is chiefly met with iff the Avorks of the ancients, " Nam qux a priscis medicinx con- " ditoribus aphthx describuntur, adeo a nostris diversx sunt, utr " toto coelo distent."* It has already been observed that aphtha: are less a disease of warm, than of cold climates ; so that many doubt Avhether the true aphthx were at all knoAvn to the ancients, and think that we have borrowed a term from them for the name of a disease, Avhich was unknown in the times and countries irt which they practised.f In the works of Hippocrates, Aretaeus, and Galen, Ave not only find, mentioned under this term, affections of the mouth different from aphthx (small sores for instance on the inside of the cheeks and about the lips) J but also similar erup- tions in other parts of the body, particularly in the genitals. A pustulary eruption of these parts, independent of any venereal affection, is not uncommon, and seems frequently the consequence of cold, of which 1 have knoAvn seA'eral instances. Besides these, there are other eruptions termed aphthx by the ancients. The reader will find an account of many of them in the Avorks of Fernclius,|| and in those of Sennertus in his chapter entitled, de Oris Inflammationibus et Ulceribus. 2. Of the Causes of the Aphthous FeA'er. It has just been observed, that this disease is more frequent in cold, than in Avarm and temperate climates. In the southern parts of Europe indeed it is hardly known ; while in Holland and other northern countries there are feAv diseases more frequent. Van SAvieten observes, that Avhiie he practised in his native coun- try (Holland), there were fcAv symptoms Avhich more frequently occurred to him in acute diseases, whereas at Vienna he had not met Avith a single instance of aphthx in the space of five years. , Aphthx are most frequent in low marshy situations, and in spring and autumn, particularly in the latter when it is unusually moist, and follovvs a warm and moist summer. In short, cold * Ketelaer de Aphthis Nostratibus. X Sennertus asserts, on the authority of Aretxus, that aphthx were common in Syria and Egypt; but the complaint mentioned by Aretxus is not tiie same with that now termed aphthx. X Van Swieten describes a thrush of a peculiar kind, which he thinks the same with one of the species of aphthx mentioued by Aretxus. it was epidemic in Holland in the 18th year of the present century, appear- ing in small ulcers about the lips, cheeks, and gums, and when neglected on account of the little uneasinass it gave at first, quickly eroding the parts it occupied, and forming putrid sores. This complaint, like the tine thrush, Avas most apt to attack children, ancl when it appeared ia adults was generally milder. U Feme-lii Uiiiversa Medicina. 312 APHTHOUS FEVER. and moisture are among the principal causes of this complaint In Zealand, which lies loAver than the surface of the sea, which is pre vented.from overflowing it by raised banks, aphthx arc so frequent, that Ketelaer calls them the endemic distemper of tho island. Although aphthx appear in people of all ages, infants and old people, Boerhaave observes, are most subject to them. In many parts of Holland, it is unusual for a child to escape aph- thx during the first month ; but they are generally of so favoura- ble a kind, that in most cases medical assistance is not necessary. In old people, in Avhom they generally appear during fevers, they arc for the most part of a bad kind, and often prove fatal. Such are the circumstances which may be regarded as the pre- disposing causes of aphthx, for although cold ancl moisture have a principal share in producing the disease, the application of some other cause in general seems necessary, since the majority of children in most countries, however cold and damp, escape it. One of the principal exciting causes appears to be derange- ment ofthe primae vix. It was observed that aphthx are frequent* ly preceded by symptoms indicating such derangement. It has been an observation, says Arnemann, from the days of Hippocrates even to our own times, that impurities of the primx vix are con- joined with exanthemata ancl other cutaneous diseases; ancl daily experience evinces, that derangement of these passages tends to vitiate the skin in various ways. " Signa prxterea aphtharum," he adds, " eruptioni prxcedentia et socia symptomata sat super- " que declarant, mali nostri fomitem in primis viis unice " quxrendum esse, communi omnium cutis exanthematum sca- *' turigine. Indicant, aphtharum ex abdomine originem nausea, " vomitus, diarrhcex male olentes, fecium color viridis, mucus ct " colluviesovorum albumini quandoque non absimilis. Quin adeo " prxdixit cl. Oosterdyck futuram aphtharum eruptionem, ex " anxietate, pondere stomachi, sensuum confusione, somnolentia, " singultu, tussicula sicca, et frequenti screatu." But these things, he observes, are so well known, that 1 might appear te- dious were I any longer to dwell on them. We shall also find, that some arguments in support ofthe opin- ion, that aphthx are occasioned by impurities of the alimentary canal, may be drawn from the mode of treatment. It does not appear, that such affections of the primx vix do al- ways, by their local irritation, first produce the aphthx in the stomach and bowels, which afterwards spread to the fauces; but from the sympathy of parts, they occasion their first eruption in the fauces. From what has just been said it follows, that the various causes of derangement in the alimentary canal are to be regarded as oc- casional causes of aphthae. One of the chief of these is worms, APHTHOUS FEVER, $15 and it appears to be in this Avay that these two complaints arc so frequently conjoined. Bad milk often has the same effect; Lieu* laud observes, that a drunken nurse often occasions aphthrc in the infant, and the same may be said of Avhatever else disturbs the nurse's health, such as anxiety, violent passions, Sec. Some suppose that bad milk may operate in another Avay in producing aphthx, by irritating the fauces, and it would be dif- ficult to ascertain that aphthx proceed from the action of the milk on the stomach ancl intestines alone, although there are many reasons to believe that this is the case. There can be little doubt however, that more poAverful irrita- tions of the fauces are sometipies the exciting cause of aphthx. Sennertus-indeed esteems local irritation in the mouth a frequent cause ofthe complaint. " Gignuntur aphthx interdum primario " in ore, dum ibi pravi humores coilecti sunt, quos natura foras li expellat." And Dr% Home in his Principia Medicinx enume- rates among the causes of aphthx " Frictio oris ab externis cau- " sis," and violent exertions in sucking. Nay the former author even thinks that where they arise from the morbid contents of the stomach, (hey are occasioned by these, or an acrid vapour ari- ' sing from them, being thrown upwards and immediately applied to the fauces. When wc reflect however, that derangement of the alimentary canal frequently occasions.eruptions on the skin, as well as in the fauces, this opinion appears yery improbable. In the same way, we may account for an increased secretion of bile proving the cause of this complaint. Fernelius considers this one of its most frequent causes. It has not however been generally so regarded; an immoderate secretion of bile beinor rare in those countries where aphthae prevail. Such are the chief circumstances which have been determined respecting the causes of the aphthae infantum ; yet in- many cases they do not seem to proceed from any of those Avhich have been mentioned ; and in a still greater number of instances, these causes- are present, without producing the disease. Still lessisknoAvn respecting the causes which give rise to aph-' tine in adults. The presence of the different diseases in which they occur may doubtless be looked upon as the predisposing causes, and in considering in what kinds of* fevers they most fre- quently make their appearance, we found certain circumstances, besides affections of the primae viae, namely, unusual deficiency of perspiration, ancl the presence of the miliary eruption, favour- able to their appearance. How these circumstances tend to produfce them, or whether or not they and the aphthae arise from the same unknown cause, it is impossible for us positively to determine. It has already been hintet), that the sympathy] which subsists between the different V**.. I. Qq £14 APHTHOUS FEVEIT. parts of the alimentary canal and the skin, may explain why affec- tions of the latter arc frequently accompanied by aphthae. Wc know thatxlerangement ofthe stomach and bowels produces aph-* thae, and nothing injures the functions of these organs more than causes affecting the perspiration. 3. Ofthe Treatment of the Aphthous Fever. The treatment of aphthx may be divided into tAvo parts. Tn the first, we shall consider the cure of idiopathic aphthx, the aph- thx infantum ; and in the second; the mode of treatment when aphthae appear in fever. As for those cases in which aphthx su- pervene in dropsy ancl other complaints, unaccompanied by fever, their treatment is in no respect different from that of idiopathic aphthx, except as far as the treatment of the primary disease renders it so. We are in the first place then, to consider the treatment of idiopathic apthx. The first thing to be done is to remove the remote causes, if they still continue to be applied. It appears from the foregoing observations, that we have often reason to suspect the disease to arise from bad milk. The state of this should therefore be exa- mined, and if it be found that no attention to diet renders it mild and SAveet, it is necessary to change the nurse. Where\7er we suspect the disease to have arisen from the in- gesta, we must begin the treatment by clearing the primac vix. Both emetics and cathartics are recommended by those who have been most conversant Avith the disease. The exhibition of the latter requires much caution, very gentle cathartics in this complaint having sometimes induced a fatal hv- percatharsis. Children who die of aphthx indeed, even where no cathartic has been exhibited, are very frequently carried off by a profuse diarrhoea. This ought not however to deter us from employing gentle laxatives- at the commencement ofthe complaint, especially when it seems'to*arise from the cause just mentioned. It is in fact one of the best means of preventing profuse purging, since the irrita- ting matter, when suffered to accumulate in the alimentary canal, increases the morbid affection of the intestines. Sydenham, it was observed, remarks, that he has often seen aphthx induced by stopping a diarrhoea, and thus confining irritating matter, which, together with that produced by the disease itself, often gives rise to the fatal purging just alluded to. But Avhether it has this ef- fect or not, the retention of irritating matter in the primae viz must increase a complaint, which it is capable of causing. Those were the worst ancl most dangerous cases, Ketelaer from very extensive experience observes, in which evacuations were not employed in the beginning. APHTHOUS FEVER. 3 ns 'Thus far then the practice seems well ascertained: a gentle cathartic is proper in all cases Avhen we see the patient at tho ■commencement ofthe disease, particularly where there is reason tto suspect irritating matter in the alimentary canal. Nor should the disease appearing in the mildest form, induce us to neglect this precaution, which can never do harm.* If there is much acid in the primae vix, absorbents are proper, and magnesia is rpreferable to chalk, as it forms Avith the acid generated in the bowels a cathartic salt. Dr. Aery, in the second volume of the Medical Museum, says that lie has almost entirely laid aside .other remedies in the thrush, confining himself to magnesia in .small doses; and Avith this practice for many years he had lost only one in thirty. Dr. Underwood also trusts chiefly to absor- bents in mild cases.t Should the purging, however induced, shew a tendency to be- come excessive, which is always attended with danger in this complaint, we need not hesitate to exhibit a gentle anodyne, after .the matter avc wish to expel is evacuated. Lieutaud remarks, .that anodynes are not only innocent but useful in this complaint, when cautiously administered, even Avhere they are not used with a vieAV to check immoderate catharsis. It sometimes though rarely happens, that symptoms denoting ,a tendency to visceral inflammations shew themselves. In such cases it is better to permit the purging to continue till the symp- toms are relieved, and at all events not to check it by opiates. But children are much less subject than adults to such inflamma- tions, and the chief danger in the aphthx infantum arises from .debility. When there is no tendency to excessive purging, opiates per- •Jiaps may be omitted, unless they be necessary to procure sleep, , * The syrup of rhubarb has been recommended as one of the best .ca- ..tliartics in this case. The preparations of rhubarb, while they evacuate the intestines, tend at the same time to strengthen the digesting organs. Tney are all apt however, especially when given alone, to occasion much griping. Rhubarb and-magnesia, are much recommended as a cathartic i.ir children by Dr. Underwood, in his Treatise on their Complaints. Mauna and the cassia fistularis, recommended by Dr. Cadogan in his work on the Management of Children, as less irritating than rhubarb, in the present case are perhaps preferable to it Myrobalar.s are possessed cf virtues in some degree similar to those of rhubarb, and are recommended by Van Swieten in this disease. Myrobalans are the dried fruit cf a tree /growing in the East Indies, with which botanists are not well acquainted. Their taste is astringent; they strike a black colour with chalybeate solu- tions, and are even employed by the Indians for tanning leadier. T4ieir purgative virtue is trifling. To the case before us, where much purging is dreaded and the patient very young, they seem well adapted, and the authority of Van Swieten, who was well acquainted widi tlie aphtha; in- ■f uitum, in their favour is not to be overlooked. They have been rejected however from the catalogue of simples by the colleges of London and Edinburgh. "••'' \ See Underwood on die Diseases of Children. 316 APHTHOUS FEVER. when they arc ahvays to be employed, except in the inflammatory cases just mentioned, proper means being used to prevent cos- tiveness. But the practice which is proper at the commencement of the complaint, i3 by no means suited to the advanced stage of it. If the disease has been properly treated from the beginning, there cannot at this period be any occasion for cathartics. But even in those instances, in which proper evacuations have been omitted tiil the disease is far advanced and the stomach and bowels are loaded Avith irritating matter, even in such cases, which seem more than any other to demand the employment of cathartics, we are not warranted to recommend them. They have often at this period induced a fatal hypercatharsis. 1 he fxces may be eva- cuated by clysters, but it is dangerous to go further. Arnemann proposes to give cathartics in small doses till the desired effect is produced, in order to guard against hypercathar- sis ; but Ave have reason to believe that neither this nor any other precaution can render their exhibition safe at the height of the disease. Ketelaer, whose opinion must have great weight, makes some excellent observations on the use of cathartics. " Exdem *' rationes etiam contra purgationem earn militant, qux cacochy- " mix propria et accommodata, ab universo corpore et ulteriori- " bus \iis, noxios quosque humores trahit. Ea hie funestissima " est, et intra paiicas horas hypercatharsi fineni vitx plerumque " facit." But there is another kind of purging, he adds, if so it can be called, which may be employed Avilh propriety, as it only evacuates the faeces, namely that induced by clysters. These medicines, he continues, are excellently suited to this disease in -which costiveness is frequent; they not only empty the intestines, thus removing a noxious irritation ; but they often relieve^ oppres- sion, and v.hut is of equal consequence frequently restore the other excretions, particularly those of the skin and kidneys, and tend to loosen the aphthx. NotAvithstanding these observations of Ketelaer however, the indiscriminate use of clysters in this complaint is often dangerous; they,have the same tendency with cathartics, though in a less degree, and should never perhaps be employed at this period, where the body is moderately open, unless the complaint be mild ancl the inflammatory tendency evident; and Ketelaer in other places makes nearly the same remark. In short, we recommend clysters at thi3 period of the aphthx infantum, to obviate restless- ness, oppression, izz. occasioned by costiveness ; and we ought not perhaps to recommend them till these symptoms begin to shew themselves. It is to be recollected, that Ave do not at this period attempt to evacuate the stomach and small-intestines, since the riok cf in- ducing hypercatharsis more than counterbalances the chance of advantu je iVom it.- If the kites tines hr.ve not been cleared at- APHTHOUS • FEVER. •sir the beginning of the complaint, this must be looked upon as* an irremediable error, andwc must patiently Avait its consequences. Hypercatharsis is chiefly to be dreaded when the disease has spread to the stomach ancl bowels. Reflecting on Avhat has been said, Ave readily perceive tho ef- fects to be wished for, arid those to be dreaded, from clysters. By an attention to these, Ave determine Avhut tlie composition of the clyster ought to be. The first thing we have in vieAV is to evacuate the fxces, with as little irritation as possible ; the clyster must therefore be mild, it should consist chiefly of water gruel or some other mucilagin- ous decoction. Some have recommended the addition of a ca- thartic, but this should only be had recourse to when a milder clyster is found insufficient. We have also in viewto relax the excretories. lew things tend more to promote diaphoresis than a quantity of diluting fluid received into the stomach or intestines, and we have seen that according as the perspiration is free, the disease is often mild or otherwise. On this account the quantity. injected should be considerable. When the" aphthae spread to the great intestines, Avhicli it was observed they often do, and even appear externally about the anus, clysters serve a further use, in lubricating and softening the parts to which they are.im- mediately applied, and thus disposing the aphthae to fall. In short they produce effects similar to those of gargles in the fau- ces, and should therefore in these cases he gently detergent, as well as mucilaginous. When such clysters are found to produce but little evacuation, of the faeces, Avhich is often the case, they maybe repeated frequently. That I may give at one view what is to be said of the employ- ment of cathartics in the aphthx infantum, which forms a very principal part of the treatment, it is to be observed, that there is a period of the disease, which succeeds th.it i am speaking of, in which their exhibition again becomes proper. We must, says Arnemann, be careful not to eri.ibit purga- tives while the aphthous crust stiii adheres to the intestines aad their surface is raAV and excoriated ; but they ar j necessary ia tlu beginning of the complaint, and-in its decline, when the aphtiix begin to fall, and are passed by stool. They.arc then seivL^.:;!e by expelling the fallen aphthx which, wiien. ai-o.ved to romri'.i, soon begin to corrupt and produce a new train of morbid symp- toms. But even after the aphthx begin to fall, the danger of hyper- catharsis, as might be supposed fro a the observations of Ai.ie- mann, is by no means passed, and sometimes .searccly at all les- sened. There are several ci.cumstances .to he. attended to in recommending cathartics mtari period. We must not, as s»oon $4t APHTHOUS FEVE*. as a few aphthae are thrown out by stool or vomiting, order acj*- thartic ; w^ must wait at least twenty-four hours after this .ap- pearance, in order to learn whether the separation of the aphthae be really the solution of the disease, or merely partial and suc- ceeded by a fresh crop, which is known by the symptoms suffer- ing no abatement. In this case nothing more than an emollient clyster is to be recommended. When on the other hand the symptoms abate, and particularly if the aphthx of the fauces fall, leaving the parts they occu- pied clean and moist, which is a sign, it was observed, of their not being about to return, a cathartic is not only safe but necessa- ry. If irritating matter in the primae vix is capable of producing the disease, Avhere it had not previously existed, it may certainly be the means of renewing it. In short, cathartics are to be employed in the decline of dp disease as early as can be done with safety. However flattering the state of the patient may be, hyperca- tharsis may be induced by a rough cathartic. The intestines ■are often left by this disease in a very irritable state, and the proper choice of a cathartic is therefore a point of much conse- quence. On this subject there is little to be added to what has al- ready been said. Rhubarb we still find particularly recommended by those who have practised extensively in this disease. Calo- mel has been much recommended, but this, and still more scam- inony, which is also employed, are certainly exceptionable.* Such are the circumstances to be attended to in the employ- ment of cathartics in aphthae, without an attention to which, the practitioner must often be guilty of fatal errors. Emetics may also be beneficial or otherwise. At the commencement of the complaint they serve tlie same purpose as cathartics, by evacuating the morbid contents of the alimentary canaL At this period however they are on many "ac- counts preferable to cathartics; their operation tends to Aveakeu less, and is particularly easy in young children, Avho seem often *o vomit with scarcely any uneasiness. Besides, the cause of Che disease seems often lodged in the stomach rather than in the intestines. It is an organ of greater sensibility. Its affections produce greater and more sudden effects on distant parts. If aph- thx be ever produced by acrid matter applied to the fauces, it ii chiefly from the stomach that such matter comes. A pain In the stomach and vomiting more frequently precede the appearance of aphthx, than a griping or diarrhoea ; in short the stomach is that part of the primx vix which seems most connected with the * Has calomel any specific power in this disease as" Wt shall find it has in many other inflanimatoiy affections} If net, less 'irritating cathartra •re certainly preierabhs kPHTHOUS FEVER. «i£ state of the disease, It is not surprising therefore,' that at its- commencement emetics are often attended with the best effects. Arnemann extols them above every other remedy. " Emeti- « ca infantibus prxscripta, omnibus medicamentis reliquis palmam " prxripere videntur, quando morbi fomes in ventriculo adhuc la- " tet, et anxietas, singultus, ructus male olentes vel vomituri- " tiones ipsx adsunt." Nor are they, he adds, to be preferred to- cathartics, only because they seem better calculated for removing the cause of the disease, but also because they are found to weaken much less. They seem also serviceable, he might have added, by promoting perspiration, ancl it is probably in this way that they often relieve the disease, where the' stomach is not loaded. If however the first emetic does not bring relief, it is not prob- able that its repetition will be attended with much benefit. Emetics in the more advanced stages are either unnecessary as in mild cases, or they may do much harm where the aphthous in- crustations have spread to the oesophagus and stomach, by produ- cing hemorrhagy, excoriation, or inflammation. Dr. Armstrong and Ketelaer recommend antrmonial prepara- tions both as emetics and cathartics in this complaint. At an early period antimony is perhaps the best emetic we can employ, but in more advanced stages of the disease, should it be necessary to recommend an emetic, which is seldom the case, we must employ one Avhich we can venture to prescribe at once in such a dose as secures its success. In this case therefore, ipecacuanha is -preferable to antimony which must be given in small doses and may consequently pass the pylorus and excite purging. Disputes have arisen respecting the propriety of blood-letting in the aphthae infantum. Some asserting that all periods of the , complaint are equally proper for the employment of this remedy, should inflammatory symptoms appear; others deeming it so , dangerous to let blood after the appearance of aphthx, that there is scarcely any symptom which will induce them to recom- mend it. Reflecting on the nature of the complaint, the question seems- * priori easily decided, and the judgment we are thus led to form is sanctioned by experience. Whatever other effect venesection produces, it always diminishes the strength. The question then is, are there any of the symptoms of the aphthae infantum which we would endeavour to remove at this risk ? In perhaps ninety of a hundred cases there are not. In by far the majority, the cau- ses of debility arc more to be dreaded than any other. AncTin these circumstances who Avould think of adding one more to the «u,mber, and that the most powerful of aR? If the excitement is such as threatens danger, or visceral in- flammation has supervened, wc must have recourse to blood-let- 320 APHTHOUS FEVER. ting ; but the latter seldom, and the. former almost never, occurs in tlie aphthae infantum. When such symptoms do occur, blood-letting may be employ- ed at my period of the disease, but with the more caution the more it is advanced. Such is the practice warranted by experi- ence, and with respect to assertions which prc-conccived opinions have extorted, even from the best writers, they deserve little at- tention. " Omnem ipitur, prxsentibus aphthis," says Kete- lae,-, "incisionem venx hue usque damnamus, atque proscribi- " mus." But in another place the same author admits, that plen- tiful blood-letting is necessary when an internal inflammation ■su- pervenes at any period of the disease, ancf gives a case in which it saved the patient's life. The diet in this complaint requires some attention ; on this however there, is little to be added to what was said of diet in sy- nochus. When fever is present, the diet must be regulated by an attention to the febrile symptoms. If the excitement be con- siderable, it must be light and diluent ; if loo low, as happens in the majority of cases, the diet must be more nourishing ; but in all cases it should be mild and mucilaginous. In most cases it is proper to "give cordials* composed of a little wine and aromatics, and sweetened with sugar. If the patient be at the breast and can suck, good milk of course must form the principal part of the diet. Where deglutition is wholly prevent- ed, mild nourishing clysters have been recommended, and are often serviceable. It only now remains to make some observations on the local remedies employed in the aphthx infantum ; and these, in the mildest cases where the aphthae spread no farther than the fauces, ancl where there is no general affection of the system, are all th^ is necessary. As it is impossible to make infants wash the mouth with anyi thing and fhen spit it out, the applications made to the internal fauces must either be such as may be swallowed, or they must be applied in very small quantity, by means of the finger, or'a bit of rag. The former are not only useful by their effects',in the fauces, but serve a similar purpose in the stomach and intetjr, tines when the aphthous eruption has spread to them. They are generally composed of mild mucilaginous and gently stimulating decoctions. The decoction of turnips or turnip-radishes, or their expressed juice mixed with water, and sweetened Avith sugar, or .honev which is better, may be given in the quantity of a dram or two every half hour. The common people in Holland use small beer or ale sweetened with sugar. Van Swieten recommends * For the use of the bark in thiscomplaint, see what is said of it when speakingof local remedies. It will then be necessary to' mention it, and jtwill save repetition to throw together tiie few observations to be mack oniU APHTHOUS FEVER. S21 Veal broth, boiled with rice and bruised turnips, which has the advantage of being an excellent article of diet in this complaint. It has already been hinted that when the rectum is affected, mild injections are proper, and produce effects similar to those of gargles in the fauces ; they should consist of such decoctions as those just mentioned. The ingredients left, after the preparation of some of these de- coctions, are often applied to the external fauces by way of cata- plasm, and sometimes relieve the internal parts. More stimulating remedies than those just mentioned, seem in many cases to produce better effects. Dr. Armstrong found a solution of white vitriol, in the proportion of about half a scruple to eight ounces, very successful, occasionally adding a little more of the vitriol. And about a dram of this mixture, he observes, now and then swallowed is of service by cleansing the stomach and bowels. He generally applied it however by means of a piece of rag three or four times in the twenty»-four hours. We shall have occasion to consider more particularly the dif- ferent applications to the uiternal fauces, indicated Avhen a ten- dency to gangrene shews itself, in speaking ofthe cynanche ma- ligna. Much difference of opinion has arisen concerning the use of refrigerant and astringent gargles in aphthous affections. Prac- titioners having observed, that in certain cases an darming train of symptoms sometimes attend the sudden retrocession of aph- thae, have avoided such gargles. Ketelaer reprobates them in the strongest terms. This is not only reasoning a priori, but reasoning also on very bad grounds. It is a mode of reasoning however that has beeu very generally adopted by Physicians, and it may not be impro- per to take this opportunity of making a few remarks upon it. In almost all the exanthemata it now and then, though rarely, happens, (for such cases are much less frequent than the fears of some writers have inclined them to suppose) that the eruption suddenly disappears, a train of symptoms supervening, which, if effectual means for restoring the eruption are not speedily em- ployed, often terminates in death. This accident I shall fre- quently have occasion to notice in considering the exanthemata, and shall point out its causes, and the means to be employed when it happens. It has been inferred, that the train of symptoms which attends the retrocession of eruptions, is its consequence; and that the same effect will follow if Ave repel, or even retard the eruption, whatever be the means employed for this purpose. This mode of reasoning is similar to, and equally fallacious with, that employed respecting the solution of fevers by crises. Fr ,m observing that a spontaneous flow of sweat, for instance, o£- \ ol. I. R r sw APHTHOUS FEVER. ten attends the change from fever to health, it was inferred, tfie* the same beneficial effects are to be expected from a sweat how- ever excited. This inference, it was remarked, when speaking ofthe crisis of fevers, is invalidated by reflecting, that the sweat- ing, instead of causing the solution of the disease, may only be a symptom of recovery ; and that it is so seems probable since forced sweats rarely induce a crisis. There is precisely the same fallacy in the reasoning employed in the case before us. Although dangerous symptoms are some- times observed to supervene on the eruption spontaneously dis- appearing, it is by no means an inference from this, that the train of unfavourable symptoms is occasioned by the retrocession ofthe eruption ; both may be the effects of a common cause, the disap- pearance of the eruption being the one of the unfavourable symptoms, and having no share in producing the others. And that this is generally the case appears highly probable, when Ave knoAv, that the accompanying symptoms often appear a short time before the retrocession, ancl that it is in debilitated states of the system, and after debilitating causes have been applied, that the retrocession generally happens; circumstances sufficient to ac-' count for the symptoms that attend it, ancl which often produce the same train of symptoms in cases where there is no eruption. And that such symptoms will not follow the retrocession or re- tardation of the eruption, except the body be somehow or other peculiarly predisposed to them, appears from numberless facts,. which seem at first accidentally to have obtruded themselves on the attention of physicians. Thus we know that retrocession in the small-pox or miliary fever has been accompanied by the same symptoms which attend the retrocession of aphthx. In a thou* sand cases however the most vigorous means for-repelling the eruption in the small-pox and miliaria are every day employed? and they are actually impeded ancl kept back, and yet no bad con- sequences, but on the contrary, the best effects, ensue. It is true indeed, that when the eruption is recalled, the unfa- vourable symptoms generally disappear; but what are the means of recalling the eruption ? Those which obviate the debility that occasioned its retrocession ; ancl we have reason to believe, that the relief obtained is not the consequence, but the cause of the reap- pearance of the eruption. In considering the propriety then of astringent gargles in aph- thx, let us appeal from the doctrine of retrocession to simple fact. Have astringent gargles been employed in this complaint, and what have been their effects ? They were empjeyed in cases of aphthx as early as the days of Sydenham; for ibis author used. the bark in fevers, while aphthx were present, and found that tbe fever yielded and the separation of the aphthx was pro- moted by it. Such was the dread of astringent applications while aphthx Avere present,thatj even in typhus, long after the ben- APHTHOUS FEVER. 52: «fit derived from the bark in this fever was ascertained, the appear- ance of .aphthx was deemed a sufficient reason for avoiding it, till Sydenham and some other practitioners ventured to employ it. I Avas encouraged to give the bark in debilitated aphthous patients, says Van Swieten, in Avhom the incrustation often became very thick. It Avas given in decoction, because the powder is not easily swalloAved Avhen the fauces are covered Avith aphthae. I did not give the bark in those cases without some fears that by its astrin- gency it might do harm ; of two evils however the best that could be clone Avas to choose the least. I therefore continued to give the bark, interposing between the doses emollient decoctions, to correct any hurtful tendency it might have. I had not, he adds, continued this practice long, before I was astonished to find that the aphthae terminated favourably in those patients who took the bark, sooner than in those who did not, although the latter were not only stronger but had also less fever. So thoroughly now are practitioners convinced of the safety •of tlie bark in aphthous complaints, that they not only use it oc- •casionallv as a gargle, but give it internally in large doses, even where there is no fever, if the disease threatens to be alarming ; and its decoction is very generally recommended in the mildest cases.* The same objections have been urged against the use of acids, tending, it was supposed from their refrigerant power, to repel the eruption, and particularly againut the sulphuric acid on ac- count of its astringency. Some practitioners however have been bold enough to employ them, and have established the propriety of doiug so.f The muriatic acid properly diluted, has been found particularly useful. "Such is the treatment of the aphthx infantum, and from what has been'said may be readily collected the treatment ia every oth- er form of the disease. With regard to the treatment of symptomatic aphthae, it seems to be much more simple than many have imagined. It is not dif- ficult to perceive how hurtful many of the prejudices just men- tioned must prove, if permitted to influence our practice in every complaint in which this .eruption occurs. What would be the consequence, were we, for instance, in synocha to abstain from blood-letting, or in agues and typhus from the bark, as soon as aphthx make their appearance. If these prejudices demand no attention while the aphthae are the only compiaint, they certainly demand as little when they are merely a symptomatic affection, * See the observations of Boerhaave, Van Swieten, Ketelaer, and those of Vogel in his Prxlectiones deCog. et Curand. Morbis. t For'a variety of applications to the internal fauces, see Vogel and others on Aphthous Fever. For easing the pain of the excoriated fauces, Burserius recommends a mixture of the yolk, of eggs cream, and syrup of poppies ; when the salivation is considerable, a ueeoc.tiwi cf agrimony with honey ; when it is obstinate and profuse, gentle astringents. 334 VESICULAR FEVER. and Avhen neither their appearance nor falling materially affect* the primary disease. When indeed aphthae prove critical in fevers, which rarely happens, it would be improper to employ any means Avhich might tend to impede the eruption. The use of astringent gargles even in this case has not, as far as I know, been found injurious. From analogy hoAvever Ave should be inclined to avoid them. It is improper, Ave knoAv, to check other critical discharges, those for instance by SAveat or stool. It only remains to make a few observations on certain sympt- toms, the treatment of which does not fall under the general plan of cure. Those which chiefly demand attention, are profuse diarrhoea Or hypercatharsis, and the symptoms Avhich attend retrocession. It often happens indeed that in neither of these Ave can be of any service. In the latter Ave must trust chiefly to tonic medicines. The eruption seems to recede in consequence of debility, and when this is obviated, 'it often reappears. Bark and astringent wines are the remedies chiefly to be depended on. Thus the remedies which have been supposed capable of occasioning retro- cession, are not only the best means of preventing it, but also of obviating the danger which attends it. Gently stimulating appli- cations to the internal fauces are also sometimes of service in recalling the eruption. With regard to hypercatharsis, we must endeavour to check it by opiates and astringents. Of the latter, gum kino and the ex- tract of logwood seem the best for this purpose. Where there are symptoms of acidity, the mistura cretacea should be joined with these medicines ; but caution is requisite in checking pur- ging, and the diarrhoea which occurs in the decline of the cuseas« and throws out the fallen aphthx, if not profuse, is salutary. SECT. IV. Of the Vesicular Fever. CONCERNING the characteristic symptoms of this fever there has been sortie dispute. It is defined by Dr. Cullen, " Typhus contagiosa, primo, secundo, aut tertio, morbi die, in " variis partibus vesicidx avellanx magnitudine, per plures dies " manerites, tandem ichorem tenuem effundentes." Dr. Cullen never saw the disease but once, and some of those who haVe had more frequent opportunities of observing it have proposed considerable alterations in his definition. Dr. Dickson* observes, that he doubts much Avhether this disease should be * See his paper on Pemphigus (the name by which this fever is,gene- rally known;, in the Transactions of the Royal Irish Academy in 1787. VESICULAR FEVER. 315 considered contagious. He saw six cases of the complain^ in none of which it Avas received by contagion, nor communicated to those Avho attended the sick. He also objects to that part of the definition in which it is said that the eruption appears on the first, second, or third day, as he observed it appear on other days of the complaint. *Per plu- res dies manentes, he also thinks exceptionable, as he never found them remain for many days. The fluid of the A-esicIes, instead of being a thin ichor, as men- tioned by Dr. Cullen, was a bland, inodorous, and insipid fluid ; and lastly he observes, instead of being poured out, it Avas gene- rally absorbed. He therefore proposes the following instead of Dr. Cullen's definition. <* A fever accompanied with the successive eruption from dif- •' ferent parts of the body, internalf as well as external, of vesi- " cles about the size of an almond, which become turgid with a " faintly yellowish serum, and in three or four days subside. This definition is certainly preferable to that given by Dr. Cul- len, not because the disease never appears in the form described by the latter, but because it sometimes does not', and it is neces- ry to have a definition including every form of it.' Notwithstanding the observations of Dr. Dickson, Dr. Cullen's definition applies perhaps to the generality of cases. On the Continent, where the disease is more frequent than in these king- doms, it seems generally to assume the appearance described by Dr. Cullen. The blisters in particular are generally filled with an acrid serum, which is discharged not absorbed.!: Mr. Blagden, in a Letter to Dr. Simmons, relates two cases of pemphigus which fell under his care, and seemingly with a vicAV to Dr. Dickson's observations makes the following : " And now li I may be permitted todraAV the following conclusions, that the " pemphigus is contagious,|f that new vesicles in every case do " not arise after the end of the fourth day, that the fluid they con- " tain does not in every case, even of pemphigus simplex, ap- " pear to be of a bland nature, and that in some instances no ap- " parent absorption takes place." In short, the cases which Mr. Blagden sav\r, very accurately correspond to Dr. Cullen's defi- nition. There is another letter indeed on the same subject also addres- sed to Dr. Simmons by Mr. Christie, whose observations agree better with those of Dr. Dickson. He thinks the disease ought * Sauvages remarks, that the vesicular eruption sometimes appears on the fourth' day. f We shall find that this eruption is not confined to the skin. X See the observations of Burserius and other foreign writers on this disease. |j One of his patients seemed to take the disease from the other. 526 VESICULAR FEVER. to be divided into two species, pemphigus simplex, and pem- phigus complicatus. But our knoAvledgeof this variety of fever is not sufficiently extensive for rendering such a division of much consequence. As we proceed in considering the symptoms of tiie complaint, its varieties, will of course be mentioned. 1. Of the symptoms of the Vesicular Fever. Of the Vesicular Eruption. This eruption appears in the form of small pellucid blisters, • similar to those produced by burning. They are of different sizes, sometimes as large as walnuts, more frequently about the, size of almonds, and often considerably less, surrounded by more or less inflammation. They appear on the face,* neck, trunk, arms, and sometimes over the whole body,t as in a case given by Dr. Stewart in the Medical Commentaries, in which the vesicles were of the size of a Avalnut, and the distance of any two of them from half an inch to three or four inches. They sometimes run ■into each other. It has just been hinted that external parts are not the only scat of this eruption. The mouth and fauces, where it uoav and then makes its first appearance, are particularly apt to be-attacked ■with it. This happened in a case related by Dr. DicksoD, in which on the third day of the fever, the patient complained of a smarting itching, ancl, as she termed it, tingling in her tongue and through the whole inside of her mouth. Her tongue was of a florid red colour, dry and clean. On the day following there appeared upon it a large pellucid vesicle filled Avith a faintly yel- lowish serum, a smaller one of the same land appearing on'the inside of the cheek. In some instances the complaint spreads along the whole ali- .mentary canal. " No person," Dr- Dickson remarks, " has no-' *> ticed an extraordinary peculiarity in this disease, that the vesi- *' cles have taken possession of the internal parts of the body, and -" proceeded in succession from the mouth downward through the -«' whole tract of the alimentary canal, some rising while others *' decayed."! The folIoAving are the symptoms which indicate that this erup- * Burserius observes, that they are particularly apt to appear on the face ancl neck. k X When they have appeared on the scalp, the hair generally falls from the places the) occupied. X He first observed this in the case of a woman treated by Dr Gregory in the Edinburgh Infirmary. In this instance, the menses had been in- terrupted tor a year and a hah, during which period the patient had been twice before subjected to the same complaint, and each time it followed a vomiting ot blood. The other case iu which Dr. Dickson met with um eruption spreading along the afimentary canal, he relates very minutely. h\ til** tu>e d>e &•« appearauce uf the eruption w;* in tiie mouth. VESICULAR FEVER. Mr tion is spreading along the alimentary canal. Great difficulty of swallowing, the vesicles in the mouth, when there are any therey at the same time beginning*to shrivel and crack, the eruption be- ing apt, in spreading to neighbouring parts, to leave those it first attacked. From these symptoms, especially if accompanied with hiccup, Ave infer that vesicles are coming out in the cesophagus. When they have spread to the stomach, the patient complains of pain referred to that organ, and nausea ; whatever is taken is* rejected by vomiting, and often mixed Avith blood. Similar symptoms attend their presence in the intestines, a general sense of soreness is felt in the abdomen, and the stools are often bloody. After the blisters have remained for an uncertain time, from one to several days, they either break, discharging in some cases a yellowish bland, in others a sharp ichorous fluid ;* or they be- gin to shrink, and in a short time disappear.. Ancl this perhaps is the most favourable termination, since when they break the/ sometimes leave troublesome uleers/f- The foregoing process does not proceed on every part of the ■ body at the same time, for the vesicles which first appear soon- est subside. From perusing the cases of pemphigus, which have been accu- rately described, we should be inclined to think that the eruption? in this complaint is most apt to attack internal parts when the matter of the vesicles on the surface is absorbed ; from one or tAvo instances however no general conclusion can be drawn. It is said, that in a pemphigus Avhich raged in Switzerland, in which the eruption often attacked the fauces, these parts were ahvays most affected when the skin was least so; but there is reason to believe that the vesicular fever has sometimes been confounded with the scarlatina, ancl from this circumstance perhaps the foregoing ob- servation took its rise. Pemphigus resembles the small-pox, in frequently leaving pits in the skin ; ancl in the parts which the vesicles occupied, remain- ing for a considerable time afterAvards of a dark colour.| * It sometimes happens in the same case, that tlie fluid in seme of the vesicles is ichorous, in others bland. See the Observations of Dr- Stcwart, above alluded to. X Mr. Blagden observes ef one of his patients, in whom the vesicle* broke, " It was very evident that the child had suffered extremely from the soreness of tiiose on the waist, Avhich were not completely healed in less than two months." It is uncommon hoAvever for them to be trouble- some for so long a time. X Dr. Winterbottom, iU the third volume ofthe Medical Facts and Ob- servations, observes of one of his patients, "When I first saw him," which was some time after he had had the disease, " his face and legs were co- " vered with spots nearly of the size of a six-pence, resembling the marks '* left by the small-pox. Many of these were attended with considerable S28 VESICULAR FEVER. The time during which neAV vesicles continue to come out is as uncertain as their duration. According to Dr. Cullen's defi- nition, no fresh vesicles appear after the third day, but this vve have seen by no means applies universally.* Swellings and abscesses of the parotid, inguinal, and axillary glands, have frequently accompanied this eruption ; and as in other cases of continued fever accompanied by these swellings, the safety ofthe patient seems often to depend on the matter formed in thern being discharged. The vesicular eruption seldom brings relief to the febrile symp- toms, but the prognosis in this variety of fever is in some respects influenced by its scat and appearance. When the vesicles ate not numerous and only appear on external parts, they demand little attention ; when they are numerous, when they attack the alimentary canal ancl are attended a\ ith a small hard pulse, the danger is considerable and is, cet. paribus, proportioned to the de- gree of these symptoms. When the ulcers left by the vesicles, although external, appear livid, shewing a tendency to gangrene, which seldom happens un- less in well marked typhus, the danger is very great. Even in idiopathic cases of this eruption, where there is no fever of any kind, gangrene sometimes supervenes, and then there is danger;! though in general, Burserius observes, where there is no fever, the vesicular eruption is unattended by danger. Ofthe Symptoms preceding and attending the Vesicular Eruption., In some cases this eruption is preceded, like those which have been considered, by anxiety and depression, but more generally it appears without being preceded by any peculiar symptoms.! A degree of coma, it was observed, frequently precedes the ap- pearance of the miliary ancl aphthous eruption, and this we shall find is a frequent forerunner of most of the eruptions we shall have occasion to consider. It has not been observed however particu- larly frequent in the vesicular fever, nor is this eruption general- ly depression of the skin, in so much as to produce suspicion, among per- sons noL much acquainted with the disease, of his really having hid the small-pox. The discolouration of the skin," he adds, "was not entirely removed tor a cwelvemonth after the disease had left bin,, but was still very evident ,n cold weather." Mr. hidden makes similar remarks: wJSTK! ? I1VC °f l.h° 1m*** of the* vesicles and cf two on the ioreneacl will ever remain. „f!; *" °h£niC °aseS llry ^^"ntinued to come out for a great length of time, fcee a case related by Mr. Christie. t Burserius relates a case of this kind which terminated fatally. X It appears from what was said of one of Dr. Dickson's patients that when tiie eruption is about to upper i„ the month, it iJ soChi"',JS Suoc^ VESICULAR FEVER. 3S9 ly accompanied with any peculiar symptoms, besides those alrea- dy enumerated, which the eruption itself occasions. Of the Febrile States in which the Vesicular Eruption most fre- quently appears. We still find the symptomatic eruptions most apt to sheAv them- selves in those fevers in which the typhus prevails. This will appear from the folloAving account, extracted from authors who regard the vesicular fever as an idiopathic complaint. In the commencement of pemphigus, as in other fevers, the patient droops and is averse to every kind of exertion. The symptoms ofthe cold stage are generally Avell marked, attended with head-ach, sickness, ancl oppression, the pulse is frequent, seldom strong and full, and delirium is a frequent symptom. It appears from what was said of the definition of the synochus vesicularis, that there is no particular period of the fever at which the eruption shews itself. It now ancl then appears in other com- plaints as well as in the synochus. See an account ofthe Cynanche Maligna in the Acta Helvetica, by Dr. Langhans. There is rea- son to believe, that in several epidemics which raged in different parts ofthe Continent, the vesicular eruption attended this com- plaint, but the accounts of them are far from being distinct. It has just been hinted, that the vesicular eruption has appeared as an idiopathic affefetion unaccompanied by fever. Cases of this kind are related by Dr. Winterbottom, and Mr. Gaitstkell in the 4th vol.. of the Mem. of the Med. Soc. of London. Burserius speaks of this eruption without fever as a frequent occurrence. 2 Ofthe Causes ofthe Vesicular Fever. The vesicular fever was unknown to the Greek, Roman, and Arabian Avriters. Some indeed assert that mention of the pemphigus is to be found in the writings of Hippocrates and Galen ; but this seems to be a mistake. There is reason to rank it among those va- rieties of disease which have only made their appearance in mo- dern times. Sauvages considers it as described by Bontius in his Medicina Indorum j but Dr. Dickson asserts, that, except one case related by Carolus Piso, he can find no distinct account of it in any author before the days of Morton, who took notice of this disease towards the end of the last century,* but without descri- bing it particularly. Sauvages met with it himself in the hospital of Montpelier, near the beginning ofthe present century, and gives the following * Burserius even doubts whether the complaint mentioned by Morton be the pemphigus; of this however there can be little doubt. See what» said in the 37th and 38th pages of the Introduction. Vol. I* £3 350 VESICULAR FEVER. account of it, "Pemphigus, febris cstacuta exanthematica hnWls " seu ampullis pellucidis avellanx magnitudine, per corpus enas- " centibus inrignita " Since his lime this disease has been de- scribed by various authors; most of what they say of it however consists in the narration of particular casts, if avc except some} for the most part indistinct accounts of it, as it raged on different parts ofthe Continent. As little has been determined concerning the causes of the ve- sicular eruption, as those of perhaps any other complaint. There is one case in which it occurred three times in the same patient, duiing a long interruption ofthe menses, and another in which it occurred twice, each time attacking the patient on a visit to a cold climate ;* yet there are thousands exposed to these causes without having this eruption. It appears from these cases, as well as one related by Dr. Hall, in Dr. Duncan's Annals of Medicine, that the disease is apt to attack the same person more than once, and that it prob.bly, like some other symptomatic eruptions, par- ticularly the erysipelatous ancl miliary, leaves behind it a predis- position to future attacks. As with respect to other eruptive synochi, some disputes have arisen concerning the contagious nature of vesicular fever. Most foreign writers regard it as contagious, and some of thecals men- tioned by British practitioners seem to support this opinion. Mr. Blagden thought that one of his patients received it from the other. Many, on the contrary, under this disease, have been admitted into public hospitals without communicating it to their fellow pa- lienis; and in most of the cases of pemphigus that have occurred in Britain, it has appeared in a single person and spread no farther. In none of those mentioned by Dr Dickson, Df. Stewart, Dr. Winterbottom, and Mr. Christie, did this complaint appear con- tagious, nor was it so in the case Avhich Dr. Cuilen saw. Dr. Hall inoculated with the matter of the vesicles without producing the disease.f It- has been proposed to divide pemphigus into two kinds, the one contagious, the other not so. The reader will find an attempt of this kind in the 106lh paragraph of Burserius's Institutiones Med. Pract. The contagious pemphigus, he observes, is al- ways accompanied with much fever, and symptoms of malignity; whereas in that which is not contagious, the fever is either mo- derate or absent. For several reasons hoAvever, Avhich will readily suggest themselves from what has been said, this division seems to be inadmissible. It is more than probable, that it has in part * See the observations of Dr. Winterbottom ancl Mr. Christie. t See Observations on the Pemphigus Major of Sauvages, byDr.lt Hall, in Dr. Duncan's Annals of Medicine for the year 1799. VESICULAR FEVER. 53J arisen from confounding the cynanche maligna with the synochus vesicularis. The truth seems to be, that the vesicular, like other sympto- matic eruptions, appears both in fevers which are ancl are not con- tagious ; and it 6eems probable, th it like these also it will some- times be propagated with the fever and sometimes not, but it does not appear, as in the case of the miliary eruption, what the cir- cumstances are which determine the vesicular to appear in fever. 3. Of the Treatment of the Vesicular Fever. The same prejudices which for many centuries did, and in ma- ny places s ill, influence the treatment of other fevers, have been ■extended to that of pemphigus. " f n Switzerland '' says M'Bride,* " the physicians began the cure with one or two large bleedings, " then b.istered the head, laid cataplasms on the neck, and en- ■" deavoured to raise sweats by sudorific medicines." As the pemphigus was considered a complaint essentially dif- ferent from common fever, particular modes of practice have been tried, and specifics looked for. •' In Behemia,"Dr. M'Bride con- tinues, " the only medicine which did service was the acetum be- " zoardicurn, and this is said to have cured all who took it, while " those who trusted to other things died." It seems more surpri- sing, that Dr. M'Bride should credit this assertion, than that Thi- erry the practitioner ay ho makes it, should either himself have been deceived, or wished to deceive others. Calomel in small dosea, followed by a saline purge, has been employed by British practitioners. Small doses of tartar emetic have also been recommended, and these iuedirii.es, as in other cases of fever, are often serviceable. 1 here is at least more to be hoped from them, than from the acetum bezo.iv'icum, and much less to be apprehended .than fro-.n profuse and repeated blood-letting, in a complaint where debility is what we chiefly dread. The result of all that has been written on the treatment of pem- phigus, as far as I am capable of judging, seems to be, that it is the same as in simple synochus, uith tlie addition of local reme- dies for the eruption, which in general seems very little to modify the fever. With regard to the local remedies, the larger vesicles aro ge- nerally opened,! and kept clean ; when any have appeared in the mouth ancl formed ulcers there, demulcent and detergent gargles are to be employed. When the ulcers either ihere or on other parts of the body become obstinate, they are to be treated by the surgeon, and therefore do not fall to be considered here. * See his Introduction to the Theory and Practice of Medicine. f The propriety of opening them is doubtful. §3» ERYSIPELATOUS FEVER. If there is reason to think, that the eruption has spread to the alimentary canal, copious draughts of some mucilaginous decoction are proper, and when the irritation is considerable and prevents sleep, if the symptoms of the fever admit of it, opiates should be exhibited, except inflammation of the stomach or bowels tu:s su- pervened ; cases which will be considered when speaking of the phlegmasia. SECT. VI. Ofthe Erysipelatous Fever. THE Erysipelas* is defined by Dr. Cullen, " Synocha duorum vel trium dierum, plerumque cum somno- " lentia, sxpe cum delirio. In aliqua cutis parte, sxpius in facie, " phlogosisf erythema.'* It was observed in the Introduction, that, although I have ar- ranged the erysipelas as a variety of synochus, because, like the foregoing complaints, it has been arranged among the exanthe- mata, yet if the view there taken of it be just, and that it is so will I think appear more fully in considering its symptoms, caus- es, and mode of treatment, it should be regarded as a combina- tion of two complaints, of synochus, and Dr. Cullen's second species of plogosis, the erythema, and consequently should have no place in a system of nosology. We shall here find the erup- tion forming a much more important part of the complaint than in the preceding varieties of synochus, modifying the general plan of treatment as well as the symptoms of the fever. * Eiysipelas is the name given this complaint by the Greeks; by the Romans it was termed ignis sacer, or merely, ignis, by which appellation it is known in many parts of the Continent; but none of these temis have been used in a very definite sense. Sennertus calls it rosa; authors how- ever have not adopted this name. By the vulgar of this country it is called the rose or St. Anthony's fire; foreign writer:, generally confine the latter appellation to Dr. Cullen's second species of it, which is also termed zona or zoster; and the erysipelas ofthe face has been termed siderotic X Phlogosis Dr. Cullen defines, " Pyrexia, partis extern* rubor, calor, " et tensio ddens." The erythema is his 2d species of phlogosis, which isdefined, " Phlogosis " colore 1 ubicundo, pressione evanescente; ambitu insequali serpente; tu- " more vixeA-idente,incuticulxsquaniulas, in phlyctamasvelvesiculas,abe- " unte; dolore urente.'' Dr. Cullen makes pyrexia part of the definition of phlogosis, and yet introduces synocha into the definition of erysipelas, in which phlogosis is mentioned. If pyrexia and synocha are not syncni- mous cerms in these definitions, the definition of erysipelas contains a con- tradiction ; if they are sync nimous terms, synocha in tHis definition is evi- dently supei-flucus. This inaccuracy proceeds from a defect in Dr. Cul- len's mode of arrangement, considered at length in the Introduction. £*e the 24th and following pages of the Introduction. ERYSIPELATOUS FEVER. S33 1. Symptoms of the Erysipelatous Fever. Of the Erysipelatous Eru/iticn. This eruption appears in the form of a red blotch or stain, which spreads with more or less rapidity. The redness some- times disappears on pressure ; sometimes it does not, arguing the inflammation having spread deeper. It is generally attended with a sense of burning and a pungent pain, but for the most part without tension or pulsation ; and the inflamed skin is not raised above that Avhich surrounds it. The parts beneath hoAvever, as well as those in the neighbourhood, are generally affected with some degree of sAvelling, which often remains after the redness has disappeared or removed to some adjacent part; for this eruption is apt to leave, or become less considerable on, the parts it first occupied, when it spreads to others. But in this respect there is much variety. After the redness has been present for an uncertain time, blis- ters of various sizes sometimes rise on the skin, generally con- taining a thin, sometimes limpid, sometimes yellowish fluid. In some cases tlie fluid is viscid,* and instead of running cut, as ge- nerally happens, when the blister is broken, adheres to and dries upon the akin. In unfavourable cases these blisters sometimes degenerate into obstinate ulcers, Avhich now and then become gangrenous. This however is a rare accident, for although it is not uncommon for the surface of the skih. in the blistered places to appear livid or even blackish ; yet the tendency to gangrene seldom spreads deep, and generally disappears with the other symptoms of ihe com- plaint. The red colour changes to yellow as the eruption goes off, and the parts on which no blisters arose often suffer a desquamation. If the colour of the eruption change from a red to a purple or blackish hue, the prognosis is bad ; but this is comparatively rare.f When the eruption has spread deeper than usual, suppurations sometimes take place, and it has sometimes happened, that ery- sipelas has renewed ulcers Avhichhad been long healed i: The period of the eruption at which the vesicles shew them- selves is quite uncertain ; the same may be said of the duration of the eruption. In mild cases it often gradually disappears, or * See Tissot's Avis au Peuple. f Platerus, Hoffman, ancl others, mention cases in Avhich erysipelas ter- minated fatally by grangrenein eld people. In the tvphus gravior it is apt to terminate in this w ay, as will pi esuuly be n.o; < \.■.-.: ticmai ly obser- ved. p X See a case of this kind in the 6th number of FJesault's Chirurgical JournaL 2-34 ERYSIPELATOUS FEVER: is carried off by spontaneous sweating, in a day or two. lu some cases it continues without beginning to decline for twelve or fourteen days, or longer. The erysipelas has had different appellations according to the appearance of the eruption, erysipelas benignum, malignum, gangrenosum, tuberculosum, scabrum, vesiculosum, pustularc, &c* Such is the general appearance of the erysipelatous eruption, but there is some variety in its appearance, according to the part of the body it occupies. In the mildest cases it eppears on the extremities ; often on the feet, and then if the febrile symptoms are moderate, if the eruption does not spread rapidly, and is only attended with a de- gree of ichiness or bvrning, or slight pain resembling the sting- ing of nettles, there is reason to believe that it will not prove troublesome, and will be of short duration. In more severe c£,:es the eruption gives more uneasiness and spreads with more rapidity. If it has appeared on the foot, it extends along the leg, the sltin over tho tibia becoming highly in- flamed, stretched, and glossy. In such cases the patient sometimes complains of tension and a sense of pulsation. This kind of pain however, as will be ob- served more particularly in considering the different kinds of in- flammation, is not characteristic of the rysipelatous. When the inflammation of the extremities is considerable, sharp pains, increased by the slightest touch, often'shoot along the muscles, and the limb is generally much swelled. Erysipelas of the feet and legs sometimes leaves an obstinate cedema. If the erup:ion attacks the trunk, the complaint is generally more severe. When it attacks the breasts of women, it is often attended Avith much 'pain, the breai'.s swell, become hard, and sometimes suppurate. The pain is also severe when it attacks the arm pits. In these and other glandular parts it often leaves the glands in a state of induration.!. Upon the whole, the erysipelatous eruption much less fre- quently attacks the trunk than the extremities. There are two varieties of it however, which appear on the trunk and deserve to be particularly mentioned. The first may be termed the erysipelas infantum. This ap- pears in children soon after birth, begins about the umbilicus, and * See Bur.^erius's Institut. Med. Pract. t Erysipelas in glandular pirts, Sc'iroeder observes, especially if cold astringent and spirituous applications have been made to it, sometimes leaves behind it schirrus of the part. Sue Schroedcr de Febre Eiysipo latosa, in his Opuscula Mriica. ERYSYPELATOUS FEVER. 33$ •ften spreads over the whole abdomen.* It is not very uncom- mon indeed for children to be born Avith the face or belly, particu- larly the parts about the umbilicus, uniformly red and swelled. It is more common however for the erysipelas to appear a few days aftc birth, and it frequently makes its first attack about the genitals. The inflamed skin is hard, and apparently very painful to the touch. This species of erysipelas h more apt than others to terminate in gangrene. The belly often becomes uniformly tense, and sphacelated spots make their appearance. Dr. Bromfield relates one case in which the gangrene in the extremities spread so deep that several joints of the fingers Avere separated. Any ap> pearance of gangrene in this form of the disease affords a bad prognosis, and recovery h very rare when it spreads so deep as in the case just alluded to. Suppuration also, though more rarely, occurs in the erysipelas infantum. r It appears from dissections mentioned by Dr. Underwood, that in this form of the disease the inflammation frequently spreads to the abdominal viscera. • The other species of erysipelas, attacking the trunk, which de- * serves particular notice, is Dr. Cullen's second species, the ery- sipelas phlyct£nodes,t which he defines" Erysipelas erythemate " ex papulis pluribus, trunci corporis partes prrccipue occupanuV " bus, et protinus phlyctsenas, sive vesiculas parvas, abeuntibus." This complaint, it was observed in the Introduction, is not very properly ranked as as a variety of erysipelas, the appearance of .the eruption differing considerably from that above described. Instead of appearing an uniformly inflamed surface, it consists of a number of little pustules,! Avhich in a short time haA'e vesicles formed on them. It generally surrounds the trunk, and appears like a red belt thrown around the body a little above the umbili- cus, from which it lias got the name of zona. It is not ahvays however confined to this part. Dr. C. Smith says, he has seen it spread round the neck and shoulders. This is generally regarded as more dangerous than other forms of erysipelas affecting the trunk and extremities. And Schroe- * See an account of this species of erysipelas in tAvo papers, one by Dr. Bromfield, and ano her by Dr. Gartshore, in the 2d vol. of the Med- ical Communications, and also in Hoffman's Practice of Medicine, and in Dr. Undcrvv ood's Treatise on the Diseases of Children. tit is this species of ervsipelas which has been termed zona nr soster. hi English it is cidled the shingles. See the 2d vol. of Burserius's Instil:. Med. Pract. Scroeder de Feb.' Fry sip in his Opusc. Med. and Vogel, Prxlect. Acad, de Cog. et Cur. Morb. X When narrowly inspected however, the erysipelas on other parts of the body sometimes has more or less cf the same appearance. 136 ERYSIPELATOUS FEVER. der indeed regards it as the most fatal of all the varieties of this disease. Dr. Smith however remarks, " This species of erysi- " pelas has been accounted extremely dangerous, which charac- " ter it surely does not deserve, unless where the patient is in the " decline of life, or the liver or some of the viscera are in a dis- " eased state, or the patient is in other respects in a bad habit of " body. I have frequently seen the disease in children and in " young people," he adds, " without a single alarming symptom." When the erysipelatous eruption attacks the face and head, it its most dangerous. It has then the same appearance as when it attacks other parts of the body. * A red spot appears on some part of the face, generally of no great extent, but which spreads till it sometimes covers, not on- ly the whole face, but the scalp also, now and then descending 9 considerable way down the neck, and occasioning whatTissot call&j " Esquinancie tres facheuse." As in other cases, it often leaves the part it first attacked, when it spreads to neighbouring parts. The face and frequently the Avhole head SAvell, sometimes to such a degree that the eyes are closed, so that Sydenham* ob- serves, the patient-looks like a person under the small-pox, only there are no pustules. The tumors of the eye-lids sometimes terminate in suppuration. The duration of the eruption on the face, as on other parts ofthe body, is various. It generally lasts eight or ten days, some- times longer. Desault in his Surgical Journal mentions a case in which it lasted 23 days. The uncertainty of the duration of symptomatic eruptions is another circumstance in which they" differ from the exanthematic. The greater danger of erysipelas when it attacks the face, arises chiefly from the inflammation being apt to spread to the braim" There is reason indeed to believe, from symptoms that will pre-' sently be enumerated, that the inflammation sometimes attacks the brain at the same time, or even before, it appears on the face. More rarely the erysipelas ofthe face spreads to the fauces ancl along the alimentary canal, Avhich is also a very alarming acci- dent. This form of erysipelas is also apt to spread to other in- ternal parts. Sometimes, Schroedert observes, it spreads to the nares, trachea, and thence to the lungs, producing all the symp- toms peculiar to inflamm.aion of these parts. It has just been observed, that when the erysipelatous eruption attacks the neighbouring parts, it often leaves that it first occu- pied ; sometimes it removes suddenly to distant parts, what phy- * See Sydenham de Feb. ErysipeL t OpusculaMed. ERYSIPELATOUS FEVER. ssr atcians have termed Metastasis takes place ; the inflammation leaving the skin, seizes on some ofthe viscera. The viscus most commonly affected is the brain, but for the most part, Dr. Cullen observes, the brain is not affected by metas- tasis, but merely by a spreading of the inflammation; as in all the cases he saw, the external affection continued and increased with the internal. Other viscera are sometimes but more rarely affected, on the sudden retrocession of the erysipelatous eruption, whether ofthe face or other parts. In metastasis of this disease, Schroeder ob- serves the inflammation also seizes the intestines, liver, uterus, ancl bladder. I shall hereafter have occasion to make some ob- servations on attempts which have been made to distinguish ery- sipelatous inflammation of internal parts from what is called phlegmonous. In the litter, the inflammation extends deeper, and differs otherwise from the erysipelatous, particularly in being more apt to terminate by suppuration. The erysipelas sometimes is not confined to any particular part of the skin, but spreads equally over the face, trunk, and extre- mities. Cases of this kind are rare; the reader will find such mentioned by Vogel and others. Sometimes, says rSchroeder, the erysipelas spreads over every part of the body, from the head to tlie ends of the fingers. This most frequently happens in the erysipelas infantum. In certain countries the erysipelas seems most disposed to at- tack particular parts of the body, thus Sauvages observes, that in Germany, the erysipelas generally seizes on the groin, thighs, and arm pits; in England and in France it more frequently at- tacks the face. Such is the appearance of the erysipelatous eruption and the manner of collecting the prognosis, as far as it depends on the eruption. It appears from what has been said that the prognosis is parti- cularly influenced by the seat of the eruption ; in the extremities it is safer than in the trunk, in the trunk than in the f ice, and, eel. par. the more extensive the inflammation the greater is tho clanger. Suppuration in general is to be regarded as an unfavourable termination, as it frequently, especially in the face, leaves trou- blesome ulcers. For when erysipelas produces suppuration, it is seldom ofthe favourable kind.* Quarin however, on the autho- rity of Strack, mentions an epidemic erysipelas, in which those recovered in whom suppuration took place, those died in whom it * See an account of the Epidemic Erysipelas, by Tissot and other* Vol. 1. Tt »3» ERYSIPELATOUS FEVERv did np^. We have reason to believe that suppuration will occur^ when we find the inflammation spreading deeper than usual, which is known by the redness not disappearing on pressure, the pains' being deeply seated, and the sAvelling considerable and hard. It was observed above, that a degree of gangrene often appears on the blistered parts, ancl if the habit of body be good, and parti- cularly if the eruption still retains the florid appearance, this ten- dency to mortification is generally superficial; but if the patient is much debilitated, especially if he is advanced in life,* and the eruption assumes a purple or livid hue, the mortification often spreads deep, and the danger is very great.! Ofthe Symptoms which precede or attend the Erysipelatous Eruft. tion. The symptoms which frequently precede the erysipelatous eruption are similar to those which precede the foregoing erup- tions; and this, like the others, sometimes appears without being preceded by any peculiar symptoms. Before the appearance ofthe erysipelatous eruption, the oppres- sion and anxiety are often considerable, and frequently attended with r.ther symptoms denoting derangement of the prima vise, a l.i-.tei taste in the mouth, foul tongue, head ach, confusion of thouiilit. vertigo, nausea, and even vomiting and purging, gene- rally of bile. Most ot the foregoing eruptions we have found con- nected wiih the state of the primx viae; this connection is not moie remarkable in any than in the erysipelatous. Anxiety, pain oi the stomach, eruc-ations, dyspnoea, nausea, and bilious vomit- ing, are enumerated by Burserius among the symptoms prece- ding, this truptipn. " Accedit non raro," Schrcecler observes of the same period of the disease, " ciborum fastidium, saporvama- u mis, ruusea, conatus vomendi, aliquancio etiam von'.itus;1' and in ar.cihei place, " Sspissime autem signa colhiviei vitioss, prx- " serum biiiosoe ad primas vias apparent.' Dr. Smith says, he has often seen erysipelatous blotches in fever where the redun- dancy of bile was apparent. Tissot and others make similar ob- servations. J-uch are the principal forerunners ofthe erysipelatous eruptipn when about to appear on the trunk and extremities. But when i» is about-to atack the face, some of these symptoms', ('particu- larly the affections ofthe head, which in such cases often rise to ■deliri«tr.);ar* aln-ost always accompanied with a greater or less 'degree of coma,} and the eruption generally appears upon the * See the observations of Platerus on what he terms Macula, Lata. | See Vegel de Cog. et Cur. Morb. ... • .,(|MJ % Mcie or k-i-s coma, as in other eruptive fevers, often precedes tlie eruption in erysipelas, Avhatever be the part cf the body v, hich theWflam- saatiui is about to occupy; but if tlie eruption is about to appear eh thr ERYSIPELATOUS FEVER. fc# •face one, or tAvo, at most three days after these symptoms shew themselves. It is from the state of the brain in erysipelas of the face, that we chiefly collect the prognosis. VV hen neither delirium nor co- ma have preceded the eruption, Avhich indeed is rarely the case, nor supervened after its appearance, there is generally little or no danger, if the symptoms of the primary disease, whether it be fever or any other, are not alarming. But when a considerable degree of coma or deli him has preceded the eruption, and still more when the coma, which often happens, rather increases than abates after its appearance, there is reason to believe that the in- flammation has spread to the brain, and the danger is then very great. ,Whep the coma is considerable from the beginning of the dis- ease, it indicates that the inflammation first seized on the internal parts, and then, in a nosological point of view, the cofriphunt must be regarded in the same light as Avhen the external infl.mimation is the first symptom of the complaint, that is, it must be regarded *impry as a case of phlegmasia; and we shall find that the treat- ment which experience has established as most successful, is the same as in other phlegmasia. From what was said ofthe tendency of erysipelas to attack in- ternal parts, it will readily be perceived, that the symptoms which ^occasionally attend this eruption mtist be very various. We sliall have occasion to consider at length the various symptoms which accompany inflammation ofthe different viscera, when consider- ing the phlegmasia:. 'r Of the Febrile States in which the Erysipelatous Eruption jf» most apt to appear. The erysipelatous eruption differs from the eruptions Ave have been considering, and agrees with inflammations, in appearins; more frequently in synocha than in typhus. On this account it generally apppears early in fevers ; so that although we find au- thors differing about the time of its appearance, it seems to be -generally admitted, thatit seldom shews itself later than the .fourth or fifth day ; but within this period the time of its appear- ance is as uncertain as that of any other eruption which has been mentioned. >■'. It sometimes appears after the fever has lasted only a few hours, in mapy cases on the second, third or fourth day ; and Avhen the fever has begun to assume the form of typhus before the eruption shews itself, if the patient's strength is not much reduced, it resumes that of synocha, the strength and the fullness trunk or extremities, the coma is much less uniformly present, and gene- rally Uss considerable, than when the inflammation is about to appear cr me'face «<• ERYSIPELATOUS FEVER. of tlie pulse increasing, often attended with a considerable de- gree of hardness. Otuer inflammations supervening on the ty- phus mitior, often have the same effect, a consequence that never attends any of the preceding eruptions, which ail tenci to increase the symptoms of debility. As the erysipelatous eruption is most apt to attend the synocha, and as the more alarming fevers generally incline lo typhus at an early period, it is in the miloer formsi of fever that this eruption most generally appears. Bui'hi erysipelas of the face, the brain is often affected ijelore the inflammation shews itself externally.* This inflammatory affection of the brain, while it induces coma, often preceded by severe head ach, sometimes by a greater or less degree of delirium, at the same time increases all the febrile symptoms ; so that although the fever which precedes erysipelas of other parts of the body is seldom alarming, that which pre- cedes erysipelas of the face frequently is so. . In such cases we have every reason to believe that the inflam- mation, although it does not show itself externally for some days after the commencement of the disease, is in fact the primary complaint, the fever being only symptomatic of it; and the treat- ment which has been found most successful, which is by no means that of an idiopathic fever, sufficiently warrants this opin- ion. The erysipelas of the face sometimes appears without any pre- vious affection of the brain, and then it is of en observed to ap- pear also without previous fever. Sydenham mentions an erysi- pelas in which the affection ofthe face was the first symptom ofthe disease. " Facies siquidern ex improviso in tumorem attolliuir, " qui subilo exorsus cum doloie ruboreque summis,. deeso niinho " marum pustularum ordine distinguitur, quae, aucta magis n> '• flammationc, vesiculas subinde.facessunt." ■* >• This eruption, like other inflammations, instead'of relieving, increases the febrile symptoms, the pulse becomes fiarccr, the nostrils, fauces, and skin more parched, and the breathing more,^ laborious, so hat the general, keeps pace with the local, a flection./ " l rocedente morbo," says Sydenham of the erysipelas, " ull " plurimum febris, dolorem, tumorem, atque alia pe.peiit symptoi " mala (qux indies ingravescentia nonnunquam in gangr,ena tcr- '• nanaiui•;, ita hasc invieem hauci meciiociem ad iebris auginen- " turn conierunt ope ram, donee lemcdiis idoneis uiraque rtstin- " guantur." «' '1 he pain," Dr. M' Bride observes, " from the in- " humiliation, keeps up the fever, until both are taken off by pro- " per remedies."t * As has just been observed, in enumerating the, hvmptoms w#ch precede chis species of erysipelas, and will more fully appear when Ave consider the diagnostic symptoms cf phreni.is. t In some rare cases however, the erysipelatous eruption has proved critical. I'ne reader will find cases mentioned by Van Swieten and others m whicn tlie tever ceased on the appearance of this eruption. ERYSIPELATOUS FEVER. 841 Nor is the affection of the brain in general reliered'by the apv pearanceof the inflammation externally, the cotna often'increrfsj) ing as the inflammation extends ; so that as this inflammation, when it makes its first attack on the face, some-times spreads to the brain without leaving the face ; when it makes its first attack on the brain, it is apt in ike manner to spread to the face ,Avithput leaving the part it first occupied, which always affords an unfa^ vourable prognosis. When the fever does not increase much after tlie appearance of the eruption, and the coma begins to abate, the prognosis is good; Soon after this the eruption generally begins to assume a yel- lovvish hue, and all the symptoms, both local and general, gradu- ally abate. Such is the general course of erysipelas of the face, and the circumstances Avhich influence the prognosis. But Van Swieten justly observes, that it is no ;nark of ignorance in the physician, although he may have considered the patient in a state of safety, when he was within a few hours of de.th ; he has of en seen cases, he continues, which from'being accompanied withlio alarming symptom, often suddenly indicated -so much danger that death'was hourly expected, the iiiflarnii ution having1 attacked the membranes of the brain. It sometimes h ippeiis, Tissot observes, that without any apparent fiui.tof tiie patient or practi- tiouer, the inflammation suddenly changes its seat, attaching the brain or lungs, and then the patient is often carried off in a very short.iaie, although, previous lo the metastasis, there seemed little or no danger. It has been observed above, that the erysipelatous eruption oft- en makes the fever resune the character of synocha after the ty- phus had commenced ; this however is only where the symptoms of typhus are not strongly marked. When this eruption appears in the typhus gravior, which is not a very frequent occurrence, in- stead of changing the nature of the fever, tlie eruption partakes of its nature, slewing a strong tendency to gangrene, increasing the debility, and consequently adding lo tiie unfavourable progno- sis. The complaint is then, what has been termed by foreign authors, febris erysipelatosa maligna or pestilens : A form ol the disease little known in this country. Ou different parts of the Continent it has sometimes been epidemic, as at I houlbuse in the year 1716, where it appeardin so dreadiul a form, that it was compared to the plague, and proved little less fatal, litis epi- demic is analogous lo those mentioned by De Ilaep,* Bart.holine,t Professor Silvius de U Boe,f and others, in which an inflammation of the stomach and duodenum accompanied tlie fever. The erysipelatous eruption is apt to appear in other complaints besides fever. 'Among the chief of ihese, Schroder enumerates * Ratio ModentU. | Hist- Anatom. Rar. hist.Sft X Prax. Ivied- Append, tract. X, bis ERYSIPELATOUS FEVER. dropsy, jaundice, wounds, particularly those of the cranium* in-, juring the .membranes of the brain,\ fractures, or considerable, abscesses in any part of the body. Erysipelas from wounds, Quarin observes, affords a bad prognosis. Erysipelas also fre- quently attends schirrus, and cancerous or other considerable ul- cers. It also frequently accompanies diseases, occasioning de-< rangernent of the prim* vise, particularly worms, and is often' one of the effects of poisonous injesta. The terms erysipelas and erythema have been used by authors in a very vague sense, the former having been assumed both as the name of tlie complaint, and of the eruption which character- ises it. Sauvages and Cullen however have confined the terns erysipelas ta the former ; and tne eruption, with its consequen. ces, they bave termed erythema But this eruption frequently occasions fever, so that Dr. Cullen has found much difficulty, both in his nosology and practice, in distinguishing the erysipelas and erythema, and this difficulty will be readi{y perceived ivnea the reader is informed .that the eruption termed erythema is pften preceded by slight indisposition, hardly, and sometimes not at ajU- affecting the pulse, so that it is difficult to say whether it has been preceded by fever or not, and" consequently av nether, according to Dr. Cullen's definitions of these complaints, it is to be regarded as a phlegmasia or exanthema. If we confine the term erythema to those cases Avhere no symp* toms of general derangement have preceded the eruption, we shall include under the term erysipelas a disease which hard* ly at all differs from erythema. Yet we must distinguish be- tween the erythema, a disease evidently referable to the phleg- masia, and in Avhich the mode of treatment is the same as ih oth. er phlegmasia, the fever being merely symptdniatic ; and the erysipelas, in which the fever is as evidently ^dioputhicy and, mast, as experience has taught, be treated as suph, execpt as far as i\ has been modified by the appearance of jtfye, Jocal affection,, The only way, as far as I can judge, to remove the difficulty, is either altogether to lay aside the, term erysipelas, regarding what is at present called erysipelas as a combination of erythema and simple fever; or, what would be preferable, to confine the term erythema to express the local affection, the simple inflam- mation which sometimes occurs without fever, and srpply that of erysipelas to the phlegmasia, namely, to those cases in which the inflammation occasions fever,f giving no name to the combination of synochus and erysipelas, which never assumes the appearance ef ancxanthema ; we might as well give a name to the combina- tion of worms and erysipelas. According to this view of the com* '* Gunshot wounds are particularly apt to produce erysipelas, and all wounds, Dr. Smith observes, which are attended with much laceration. | T:u reader will find, in perusiog4he works of those who treat of ery- sipelas, that the nature of the complaint constantly leads them ynKite'n- Monaily to use these terms nearly hi this sense ERYSIPELATOUS. FEVER. 845 plaints, the term erysipelas would be confined to the cases in which the local affection is either preceded by no symptoms of general derangement, or by such as frequently precede the locat affection in the other plcgmasi^. Tlie inaccurate use of the foregoing terms forces Dr. Cullen into a mode of arrangement in his System of Practice, by which the consideration of that form of erysipelas in which the eruption appears on the trunk or extremities is altogether omitted, for Dr. Cullen, finding the symptoms which precede the eruption on these parts often scMrifling as hardly to be perceived, and some- times altogether wanting, so that the complaint had little if any appearance of an exanthema ; but observing at the same time, fhat the preceding symptoms were very generally considerable when the eruption was about to appear on the face and head ; in treating of erysipelas he considers this ease alone. He expresses the difficulty in the 697th paragraph as follows : " 1 suppose the •* erysipelas to depend on a matter generated within the body, and * which, analogous to the other cases of exanthemata, is in con-' " sequence of fever thrown out on the surface of the body. I u own it may be difficult to apply this to every particular case of " erysipelas, but I take the case in which it is generally supposed '•to apply, that of the erysipelas of the face, which I shall there- u fore consider here." Dr. Cullen therefore leaves other cases of the disease, if they are considered at all, to be arranged among the phlegmasia: According to his view of the disease then, if the eruption in erysipelas appears on the face, the com- plaint is an exanthema ; if on the trunk or extremities, a phleg- masia. Can this view of the disease be accurate ? Besides, how shall we arrange the case above described in a quotation from Sydenham's Treatise on Erysipelas, in which the eruption on the face was the first symptom of the complaint ? The foregoing view of this disease obviates every difficulty, and is supported, as far as I knoAV, by every fact on the subject The erysipelas is a phlegmasia, which like gastritis, enteritis, or any other phlegmasia, sometimes occurs in idiopathic fevers.* Different divisions of erysipelas into varieties have been pro- posed by authors, none of them however are of much use in prac- tice. I have already had occasion to ailude to the division into febris'erysipelatosa benigna, and febris erysipelatosa maligna1, A variety of divisions of this complaint has been adopted by Cel- sus, Fernelius, Hoffman, and others, founded on the appearance «Pthe eruption, according as the inflammation is more or less su- perficial, as vesicles do or do not supervene, and do or do not leave ulcers behind them ; and the ulcers being superficial or deep, * The justness of tlijs view of the complaint vv ill :>c sufficiently apparent, I hope, on comparing'what Is about to be said of the causes and treatment of erysipeh^,' Arith Avhat will be said in the next volume of the nature of the phlegiuasiUs, and toe maxims which conduct our practice ui thb order, ef ^•iiiptomutiC fevers. 344 ERYSIPELATOUS FEVER* w.elj, conditioned or othcrv ise, have also afforded other useless divisions.* 2. Causes of the Erysipelatous Fever. In the causes, as intl e symptoms of erysipelas, wfe still find It partaking of the n- ture of t! e phlegmasia; with these it agrees^ and differs from symptomatic eruptions, in having been known from the earliest times. With regard to the predisposing causes, those most disposed to this comprint are ihe voimi? and people in the rigour of life, especially those of a sanguine and choleric: temperament, and ofn plethoric habit. Like the other phlegmasia, it is most apt td attack those who formerly laboured under it. The exciting causes of erysipelas also are the same with those of the phlegmasia:. One of the most frequent, particularly in those who have formerly laboured under it, is cold, especially if alternated with heat, as in variable weather. It is sometimes the consequence of excessive heat, loo full a diet, particularly the abuse of fermented liquors, the suppression of any habitual dis- charge, as the diving up of an i-sue, suddenly checking hemorr- hois, or abstaining from habitual blood-letting, or any other cause of plethora. It is frequently reproduced by local irritation, whether chymi- cal or mechanical. « As I have known erysipelas," Dr; Cullen observes. " with all its symptoms, arise from an acrimony-applied " to the part, as it is commonly attended with a full and frequently " with a hard pulse, as the blood drawn in this disease shews the " same crust upon its surface as appears in the phlegmasia, and " lastly, as the swelling of the eye-lids in this disease frequently " ends in suppuration ; so from these considerations it seems " doubtful, if this disease be properly in nosology separated from " the phlegmasia ; at any rate I take the disease I have described " to be what physicians have named the erysipelas phlfegmonodes',' " and that it partakes a great deal ofthe nature of phlegmasia." In some of its other causes.the erysipelas appears to bear*. stronger analogy to other symptomatic eruptions. It has been observed of all these, that they seem frequently to arise from de- rangement ofthe primae viae. This is not more remarkably the ease with any eruption than the erysipelatous. Such derange- ment indeed seems one of its most frequent causes. Purging, says Tissot, is in general necessary to evacuate the corrupting bile from the primae vis, which is the most frequent cause oi ery« sipelas. Such is the connexion of this complaint with the prims vise, says Schroeder, that Ave often wholly remove the disease by * See the 3d chap, cf the 4th book of the Patholc gy cf Fernelius, ai d Schroeder's Opusc. Med. See also a division of ervripelas, equally ob- jectionable, in Burserius's Institut. Med, Pract. ERYSTPElAT6US FEVER. &4S removing the irritating matter, Avhich is generally bilious, from the stomach and intestines.* The redundancy of bile in the stomach and intestines so fre- quently accompanying erysipelas, gave rise to the hypothesis of erysipelas being occasioned by a bilious st te ofthe fluids, a doc- trine! long mainta.ned, ancl adopted by so late an author as Quarin. But other noxious matter in the primae vix aho produces erysipe- las, and other eruptions we have seen, not suspected to depend on a* bilious state of the fluids, arise from the same cause. It is perhaps by affecting the state of the primae via?, that the passions of the mind, particularly rage, terror, and vexation, fre- quently excite erysipelas, and that pregnant women are observed to be particularly liable to it. | But even in these c -uses we find erysipelas resembling o'her phlegmasia:, which, it will appear in considering these complaints, more frequently arise from derangement of the prima vise than is generally supposed. Erysipelas seems also now and then to arise from other affec- tions of the audominal viscera, particularly affections of the liver.J In this respect also we shall find that the erysipelas resembles some ofthe phlegmasia;. || Erysipelas in general is not contagious, yet like other sympto- matic eruptions, as well as certain phlegmasia, it sometimes at- tend,* the prevailing epidemic, and teen the fever is generally the typhus gravior. It h tiie works of Hippocrates, Galen, Ballonius, Hoffman. Lieutaud, Tissot, Bag- hvius, Biaijclius, Friend. Riqha, Mead, Brocklesby, Zimmerman, Moli- nanus. and others of less note, to which Quarin, Vogel, Burserius, Desault, and other late Avriters may be added. Desault in his Surgical Journal re- lates several striking cases of erysipelas arising from, or supported by deYahgement of the prima viae. 'VSee this doctrine considered at length in Bureau's Treatise on Ery- sipelas. J ' tThe erysipelas infantum in particular has been observed to arise from this cause. ft It will appear from a A'ariety of observations^ that inflammations of the viscera, of the thorax in particular, are apt to arise from various af- fections of the abdominal viscera. See an Account of the Pleuritis Ver- mj^osa, iuthe.43d, 44th, and 4oih sections cf the 21st Epistle of M >rgagni. See also an Account of Dissections by Wendt in his Treatise de Pieuntide in Sahdifort's Thesaurus; an Account of the Pleuritis Piliosa in Bianchus's Historia Hepatica, and in the tifi.li volume of the Edinburgh Medical Es- says; and several papers, in .the .second volume of Hauler's Dkputaticnes act Morb. Hist, et Cur. pertinent, on the.Pueiini.^ia Putrida which ucems often influenced, if not caused, by affections of the prims via. Vol. I. U u $A& ERYSIPELATOUS FEVER. Mid. Observations, mentions an erysipelas of the head, which waa epidemic for (wo years, in which it was necessary to employ cor^ dials and Peruvian bark, anti-phlogistic measures generally prov- ing fatal. Tnstances of epidemic erysipelas are also to be found in the works of Sydenham, Burserius, Tissot, ancl others. It is remarkable that erysipelas sometimes returns periodically, attacking the patient once or twice in the year, or even once every month, and then by its repeated attacks it often gradually exhausts the strength, especially if the patient be old and of a bad habit. Hoffman mentions several cases of this kind. In one of these, the return of erysipelas was prevented by an issue and low diet; tAvo of the mc-st poAverful means, we shall find, of preventing the appearance of the phlegmasia. Vogel and Schroeder mention cases of the same kind, ancl the former observes, that those Avho are subject to erysipelas are generally free from other complaints. Schroeder mentions several instances, in which the erysipelas constantly supervened at the time the menses should have ap- peared. 3. Of the treatment of the Erysipelatous Fever. From what has been said ofthe symptoms and causes of erysi- pelas it appears, that in those cases where the affection.of the skin has been present from the beginning of the complaint, or where the complaint has been attended from the first with coma or delirium, it is to be regarded as a phlegmasia, and universal ex- perience has ascertained, that the treatment in these cases is the same as in other phlegmasia?. The treatment in such cases therefore will be considered when Ave come to speak of the phleg- masia. To the same place it is proper to refer the local treatment jn erysipelas. We are at present to consider, how far the appearance'of the erysipelatous eruption in the progress of synochus, influences the treatment of this lever. The appearance ofthe erysipelatous eruption in the first sta|e of synochus, that is, Avhiie the inflammatory symptoms prevail, the period at which it most frequently supenencs, occasions biit little change in the mode of treatment, except that as the inflam- matory affection of the skin increases the symptoms' of synocha, the means of moderating the excitement must be employed with greater assiduity. They are also safer than in other species'of synochus. It has been observed, that if the typhus has commenced before the appearance of this eruption, the symptoms of synocha are of- ten recalled by it. They are not only recalled, but maintained, for the typhus which supervenes towards the end of an erysipela- tous fever is less considerable, in proportion to the preceding ERYSIPELATOUS FEVER. *S# -symptoms, than in other varieties of synochus; the erysipelatous fever in this respect also approaching lo the nature of a phleg- masia, hence the effects of evacuations are less to be dreaded than in cases of synochus where no erysipelatous eruption supervenes. Sydenham did not scruple to employ blood-letting in erysipelas almost as freely as in any of the phlegmasia? ;* how we arc to proportion the evacuations to the state ofthe local affection will appear more fully in treating of the phlegmasia. All that need be said at present is, that the mora severe the lo- cal affection, that is, the greater the swelling, heat, pain, and ihe further the inflammation extends, especially if its seat be the head or trunk, and the greater the coma or delirium, the more powerful must the antiphlogistic measures be ; provided the pulse continues full and strong, still more if it be hard, which is gene- ■ rally"the case when the local affection is considerable. " Upon f this donclwion," Dr. Cullen observes, "• the erysipelas of the " face is to be cured very much in the same manner as phlegmo- " nic inflammations, by blood-letting, cooling purgatives, ancl by " employing every part of the antiphlogistic regimen, and our " experience has confirmed the fitness o Uhis method of treatment. " The evacuations of blood-letting ancl purging are to be em- " ployed more or less according to the urgency of the symptoms, '** particularly those of the pyrexia, and those which mark an af- " fection of the brain. As the pyrexia continues and often in- " creases Avith the inflammation of the face, so the evacuations " mentioned may be employed at any time in the course of the " disease." When erysipelas appears as a simple phlegmasia however, more copious evacuations are proper than in the case before us, where a phlegmasia supervenes on continued fever, particularly if the fever has arisen from contagion or sheivn a tendency to ty- phus. , There is anotfier caution which deserves attention in the em- ployment of evacuations in the synochus erysipelatosus. This, ,|ike other affections of the skin, which appear in continued fever, has been known suddenly to recede, an alarming train of symp- toms, of which debility is the characteristic feature, superyening. This is comparatively a rare occurrence ; as in other eruptive fe- vers, it is most apt to happen where debilitating causes have been applied. It is also to be remembered, tttat when retrocession takes place, the patient is seldom out of danger till the eruption is recal- * " Hac ut fiant, ubi primus accedo, satis largam sanguinis quantita- " tem e bvaehio extrahi pracipio, qui quidem pleuriticorum sanguinem " fere semper amulatur;' and after mentioning the other means fie em- ployed after blood-letting, he observes, " Hac methodo turn febris, turn " alia syniptomata citissime fugantur. Sin aliter, rursus venam seco, qucd "et tertium nonhunquam fieri debet interposito semper die uno, si prava " nempe adsit sanguinis diathesis ct febris intcuuor.' Sydcidiaw de Ettfc Ersipd. 348 ERYSIPELATOUS FEVER. lecj, whjqh^ ($o^e with the greater difficulty the more he is de- bilitated. The advantages of blood-letting over other evacuations for mo- derating the excitement h..ve been pointed out ; but ih* eryripe-i Jatous eruption frequentiy indicating derangt-mmt of ihe prims via. and being often inf reastd if noi caused by such derangement, a small evacuation by 'he bowels in the erysipelatous lever often produces more powerful effects than a larger evacuation by vene- section. We shall find, in considering the phlegmasia, that in all inflammatory affections of the head, purging'is particularly useful ; in the erysipelas of the face therefore it is doubly indica- ted, and in all forms of the complaint, when the symptoms are moderate, generally renders the employment of blood-letting im- necessary. Schroeder justly observes, that catharsis should ' always' pre- cede blood-le'ting in the erysipelas. One caution however' is to be ktpt in vieAv. if the loral i.ffection proceeds from, or is in any degiee caused by, affections ol the primae via, the beneficial ef- fects of purging Avill very quickly be observed, so that if it does not produce a favourable change, we should not persevere in the use of tlis remedy. frequent purging, says Quarin, especially vheie the- habit is debilit, ted unci the- pulse frequent and small1, renders the erysipelas more alarming ; but even wh*re the pulse is strong and hard, if the first exhibition of cathartics is not atten- ded with beneficial effects, h is better, for the reasons given in speaking of the modus operandi of blood-letting, to reduce the excitement by this remedy than by repeated purging. And • with regi.rd to ihe opinion, that venesection is apt to occasion^ a retrocession of the. eruption and'make it sieze upon, internal parts, the observations made on the same objection to it in other ei-upme synbofti, are applicable here \\ e need not fearfcsays Schroeder, that blood-etling wiil occasion a retrocession of ery- sipelas or make it fall on internal parts.* If the erysipelatous eruption appears at an early period of the feur, v<-niiting should precede catharsis, except in erysipelas of • thi- head, in all cases of which an emetic is at least a doubtful remedy. V, 1 i:e we endeavour to evacuate the morbid content* of the ahmei.taiy cu.rud, we should at the same tin.e correct what part * When die eruption recedes, blhters and cordials, with diaphoretics) have been K-und tiie best means of restoring it See tiie ob ervatinns of a v.u-ieiy ci auhors, parucmariy tiiose of II fTr.ian and Schroeder. " If tiie h« tiling, iaysM'Lride, " should suicienlj sink and the acrid humor appear to Mi ike in, .;etv ccn e >ee'i tlie distinct and confluent small-pox. I hey insei.rihlv mn into each other. In the worst kinds of the conflu- ent, there ..re icenerally some distinct pustules- In cases which deserve ihe name of" distinct, we often observe two or more pus- tuies running tog ther. Concerning this division then-fore it is proper to observe, that where the greater number of pustules are eritentiy confluent, the complaint has received ths one appella- tion ; when the greate: number are distinct, the other. The appearance ofthe pustules also, as appears from the fore- going definitions, as well as their number ancl degree of conflo ence, forms a striking mark of distinction between the benign and confluent small-pox. The confluent small-pox varies in the same manner as the dis- tinct ; hence the names variola confltiens crystallina, vesiculitis, siliquosa, verrucosa, &c all which varieties are attended with great danger. Most ofthe symptoms expressed by these terms are more apt to attend the confluent than the distinct small-pox. In the confluent the pustules sometimes appear almost black from a degree of mortification taking place, ancl blood being mixed v itb the nutter they contain ; hence one variety is termed Variola Confluens Nigra. When blood is effused into the cavities ofthe pustules without giving them a perfectly black appearance, the complaint has been termed Variola Sanguinea. When the pustules are here ancl there collected together in clusters, with feAv in the intermediate spaces; the complaint has been termed Variola Confluens Corymbosa. When pct» chiae appear between the pustules, it is called Va» riola Cot fluens Petechialis, or Maligna. Af er laying before th- reader the symptoms of the distinct and confluent small-pox. it will be necessarv to take notice of some of the principal varieties of this complaint, which may properly enough be termed anomalous. In detailing the symptoms of small-pox, it is unnecessary to consi er separately what has been termed the simple distinct, and contiguous c:istinct, the simple confluent- and putrid confluent- as some nave none. The two former 1 shall con.prebend under the term distinct, and the two latter under that of confluent. The SMALL-POX. ess contiguous are only the worst kind of the distinct; and the putrid the worst form of the confluent. It will be necessary to point out the symptoms which indicate most danger. Those indicating most danger in the distinct small- pox, belong to that called contiguous distinct; those ituiicating most danger in the confluent, to that called putrid. These divi- sions are of no use ; it is only necessary to take notice of them, because they have been adopted by authors. SECT. I. Of the Symptoms of the Small-Pox. IN order to avoid confusion, it will be proper to consider the symptoms of the distinct and confluent smah-pox separately. 1. Of the Symptoms of the Distinct Small-Pox. Small-Pox attacks in a manner similar to the fevers Ave have been considering. The patient sometimes complains of sickness for several days before die fever is distinctly fori ed ; this however is not very often observed. The fever generally comes on about mid-day, with the symptoms of a cold stage, often attended with a consid- erable degree of drowsiness. If the patient is old enough to give an account of his feelings, he complains of languor ancl listlessness, wiih the other uneasy sensations that attend the commencement of synochus 1 hese symptoms are soon followed by considerable heat, thirst, and the other symptoms which characterize those fevers in which the sy- nocha prevails. The skin and fauces are parched, the body costive, the urine at first pale, afterwards more scanty and high coloured, and he- morrhagies are frequent, particularly from the nose. When the small-pox is of the distinct kind, the fever which precedes the eruption, and on that account termed the eruptive fever, is al- ways a synocha, ancl the more moderate the symptoms of excite- ment are, the more favourable is the prognosis. Such are the symptoms which the eruptive fever of small-pox has in common wiih many other febrile diseases, but certain symptoms generally attend, by which the disease may be known before the eruption m kes its appearance. It has been observed, that pains of the back, limbs, and loin?, are more common ancl severe than in most oilier febrile com- plaints. The patient also -sometimes complains of pains in the 356 SMALL-POX. breast and fauces, and coma is apt to supervene.* All thes© symptoms afford an unfavourable prognosis. In adults particularly, when the eruption is about to be nu- merous, there is ofun uncommon tendency to sweat, which re- curs as ofen as the patient goes to bed.* A coldness of the ex- tremities is often present during almost the whole course of the disease, especially in children even where the danger is not con- siderable, and has been regarded as one of the best diagnostic syn.ptoms of the eruptive fever \ But the most uiv quivocal are those mentioned by Dr Cuihn in the foregoing definition, the vomiting and pain of the stomach increased on pressuie. l-.ven these however, like the other diagnostic symptoms of this fever, are not universally present.|| The vomiting is generally bilious.§ and then there is often pre- sent at the same time a degree of bilious diarrhoea. A little before the appearance of the eruption, some change in the state ofthe symptoms generally takes place. Children are subject to starting duiing sleep from the commencement of the complaint. On the night before the eruption they are ohen seized with an epileptic fit. 11 it only occui cue or twice, it is hardly n:ri, at ion, ihe eyes are glar- ing and cannot endure the lifchi, the face glows, there is a con- siderable increase of temperature, the skin and fauces become parched- and coma, although it had not sheAved itself at an ear- * Bang observes, that coma is most apt to supervene in this complain in the vigour of life See ActaS ciet .Med. Hafiu t Sv denham says, he nev er observed this symptom in children eitheu before or after the appearance of the pustules. X See Dr. Walker's Treatise on the Small-Pox. || See the observations of Van Swieten in his Commentaries, and others, on the diagnosis of this fever. § It is, difficult to say on what foundation Dr. Thompson has asserted that the vomiting is most fiequemly bilious in women and children, bee Dr. Thompson's Tieatise on ihe *• mall Pox. % Epileptic fits have sometimes though rarely recurred at a late period of the distinct small-pox. The son of Lord Sunderland, inoculated by Mr. Maitland soon after the introduction of inccutation into England, died of an eleptic ht after the greater part of the pustules were dried off. See Wcodville's History of Inoculation. SMALL-POX. 3.51 tier period, often supervenes. The patient is sometimes troub- led with cramps in the legs, and a severe pain in the back now and then conies on a short time before the appeal ance of the pus- tules. Few- of these symptoms however are observable in mild cases; the coma and cramps of the legs generally forebode a co- pious eruption The period at which the eruption appears is not exactly the same in all cases ; generally towards the end of the third day, or the beginning of the fourth, counting from the commencement ofthe febrile symptoms. Sydenham observes, that in the distinct small-pox the eruption generally happens on the fourth day, in- cluding the clay on which the fever commences, sometimes ra- ther later, but rarely before this period. Dr. Cullen makes the time of its appearance about the end of the third day. If avc class together all kinds of smal-pox, we shall perhaps find the third day the mean time of its appearance.* It is to be observed that the later the eruption the more favourable is the prognosis. The pustules on their coming out are small red points, appear- ing first on the face and hairy scalp, then on the neck, gradually spreading over the w hole body, it frequently happens that as soon as the pustules make their appearance the patient is affected with sneezing, which continues to recur while they are coming out. The interruption of this symptom has been regarded as a sign of the eruption being finished. About the fifth or sixth day, counting from the commencement of the fever, that is, the second or third of the eruption, a little ve- sicle, w hich appears depressed in the middle, is seen on the top of each pustule, containing a matter nearly colourless For two or three days the vesicles increase in breadth, the matter gradually assuming the appearance of pus. About the eighth day of the increase they become spherical, anci the pustules, are complete- ly formed ; being then very itchy, hard, ancl prominent, and appearing almost terminated in a point. When the pustules are more numerous, although benign, they neither rise so high nor are so much pointed, as when fewer in number ; but are then often rather flat on the top. * Nothing can be more vague than the mannerof ascertaining the peri- od of the eruption. The eruption is said to happen on the second, third, fourth, &c. day, vheiher it occurs in the morning or evening of these days, and whether the accession of the fever has been in the morning or evening. Great accuracy in this respect however would not be cf much consequence. It has been proposed to make every day consist of 24 hours in compu- ting the appearance of .he eruption, so that were the fever to attack to-day atone, and the eruption to appear to-morrow at twelve, it should be re- garded as appearing on the hrst day If it appears betAveen one of the second day and the same hour of the following r. should be regarded as appearing on the second day, and so on. See Dr. Thompson's Treatise on Small-pox. B58 SMALL-POX. In the most benign small-pox, from their first appearance th* pustules are surrounded wi'h a perfectly circular inflamed margin. When the pustu.es are moie i.uii.en us, Lough slid of a favour- ble kind, the margin is less ex.iotly circular. I hese inargins co- alescing in places whe e the pustules are crowded, give ;, ,ed colour to the skin Iving between them, which is always a favoura- ble appearance. In the mildest cases no more pustules appear after the end of the first day ofthe eroption, or the second at furthest. It cases where they are about to be numerous, they often continue to make their appearance a day or two longer. About the eighth day, Avhen the pustules are pretty numerous, the face swells and is often affected Avith lancinating pains. 'I he swelling sometimes extends to the whole head, the eye-lids 6eem as if cistended with a fluid, and are often so much enlarged asertirely to close the eyes. When the eyes are much affected from the beginning, the sight is sometimes lost, generally in consequence of one or more pustules forming on the cornea. '1 his indeed is a rare oc* currence. Pustules are rather more apt to appear on the sclero- tica, and there their consequences are less to be dreaded. When the 'uniefaction of the face begins to !-ubside, which happens about the tenth or eleventh day. the bands and feet smell, vriiich in the space of some days subside in like manner. All these are symptoms not very remarkable in mild cases : at the same time it is not to be overlooked, that when the other syptoms are severe, these swellings, if not in excess, are to be regarded as favourable appearances. As the disease advances, the matter of the pustules becomes by degree more opaque, thick, whitish, and at length yeilow. When the pustules are very numerous, 'he mattei is thinner and not so yellow as in the most benign forms of the disease. About the eleventh or tAvel'th day, still counting from the commencement of the fever, the pustules hu\e gained their full size, which differs a little in different epidemics, but is generally about that of a pea. A dark spot new appears on each. From being soft and smooth, they become rough •. nil throw out a yellow matter. The pustules now begin to shrink, and the mailer dry- ing forms a small crust over each of them. Sometimes only part of the matter is thrown out, which, together with that 10- maining, hardens; and, in a few days, falls off, leaving the skin in the places which it covered of a ch.rk brown colour that often remains for along time alter the patient is well. While this lakes place, the swelling of the face and other parts gradually subsides. But tin foregoing process does not go on at tlie same time on every part of the body. 1 he pustules in those SMALL-POX. 359 places on which they first appear first arrive at maturation. They generally remain longest on the hands. The sooner the pus» tules become dry and fall off, the better in general is the prog- nosis. It often happens in cases where the pustules have been more numerous on tlie face, continued for a longer time, and been filled with a matter less thick and benign than usual, that after they fall off the pails which they covered suffer desquamation, so that small pits are formed, for the pustules do not on faking off leave pits ; they are formed by a succeeding operation. Pits are seldom the consequence- of the distinct small-pox, unless the pustules are very numerous.* It sometimes happens that the matter of the pustules, particu- larly on the arms vith an increased secretion of sa- liva, the voice at the same time often becoming hoarse. A con- siderable degree of any of those symptoms tends to afford an un- favorable prognosis. As the disease proceeds, the secretion from the mouth and throat often becomes thick, and is not easily spit out, sometimes * Sydenham remarks, that when pitting follows the distinct small-pox, it is generally tiie consequence ot several pustules having run together, which usually happens, he observes, in ihe last six months of ihe year. He generally found the small-pox milder in the spring dian in the autumn. | See his Practice of Physic. X See Walker's Treatise on the Small-Pox. || Whm the tendency to sweating has cccurred. it has been observed, notwithstanding the abatement of the fever, to cunuiue ucarly to the, rime of maturation. 966 SMALL-POX. occasioning such difficulty of swallowing, that liquids taken intd the mouth are spit out again, or rejected by the nose. The swel- ling or parched state of the fauces a so sometimes considerably affects the breathing, and deafness is now and then a symptom at the same period, from a pustulary affection of the meatus audito- rium externus. These symptoms however, in the distinct small- pox, are generally of little consequence ; they all wear away as the more essential symptoms decline. When the pustules are numerous some return of fever gene- rally happens about the eleventh day, a period we shall find much dreaded in some forms of the disease; bui for the most p .rt it disappears in a few days, and in this kind of small-pox is seldom attended with much uneasiness, and less frequently with danger. But even in the distinct small-pox, when the pustules are nu- merous, a train of symptoms indicating more danger now and then supervenes at an earlier period, about the seventh or eighth day. This train of symptoms has been called the secondary fever. It sometimes happens at this period, af'er the patient has ap- peared almost Avell, he pulse having returned to its natural fre- quency, lhat symptoms of fever more or less gradually, in some cases very suddenly, return, and in ihe space of a few hours the pulse becomes more frequent, ancl the other symptoms of fever more severe, than at any former period But when this fever occurs in the distinct small-pox it is attended with less danger than in the confluent. In the former it seldom appears Avhen the pustules are of a benign kind, and almost never Avhen the patient has received the disease by inoculation and been properly treated* When the pustules are numerous they must, in many places, run together. When the greater number run together, the dis- ease is termed the Confluent Small-Pox. The symptoms pecu- liar to this form of the disease we are now to consider. 2. Of the Symptoms of the Confluent Small-Pox. Although there is much similarity in the eruptive fever of the distinct and confluent small-pox. yet, even from the commence- ment, in some respects they differ essentially. The symptoms common to both, the sensation of cold, the anxiety, sickness, vo- miting, &c. more uniformly attend and are experienced to a greater degree in the confluent than in the distinct form of the disease. The pains of the back and limbs in particular, which are only sometimes troublesome in the distinct sm dl-pox, very generally precede the confluent eruption. Van SwL-ten obser. es, that when the complaint comes on with a severe lumbago, so that the patient can hardly move his limbs, he always suspects danger. Even al- SMALL-POX. 36* though the fever be slight, he adds, these symptoms always afford an unfavourable prognosis; and Morton remarks, that he always found coma and a severe pain ofthe loins to be dangerous symp- toms in the eruptive fever of small-pox. There are few authors indeed who treat particularly of the small-pox without making similar observations. The most striking difference however between the eruptive fever ofthe distinct and confluent forms of the disease, is, that in the distinct it is synocha, never shewing a tendency to typhus, while in the confluent, although at the beginning synocha, it is apt to be changed into typhus by any error in the treatment, or even without any evident cause. In the most alarming cases in- deed the fever is a typhus almost from the beginning; petechiae, and sometimes hemorrhagies of a bad kind, appearing at a very early period. Epileptic fits now and then occur during the first days of the fever, and have even proved fatal before the eruption appeared; at other times they continue to recur after the eruption is but, and sometimes through the whole course of the disease. The tendency to sweat is not common in this kind of small- pox ; but a diarrhoea often precedes the eruption, and continues for a day or two after its appearance, which Sydenham declares he never saw happen in the distinct small-pox. If the stools are unusually fetid, the prognosis is very bad. This diarrhoea is generally confined to children ; in adults an affection of the fauces, often amounting to a salivation, attends, instead of the diarrhoea.* It was observed, that at a later period, even of the distinct small-pox, there is sometimes an increased secretion of thin saliva. The eruption in the confluent, generally appears earlier than in the distinct, small-pox, seldom later than about the beginning of the third day, and often on the second ; in some cases even before the expiration of the first twenty-four hours ; and fresh pustules continue 10 come out for the space of three or four days. Theperiod Ofthe eruption is more uncertain than in the distinct small-pox; for although generally earlier than in mild forms ofthe disease, it has been delayed by the appearance of inflammatory symptoms to the fourth or even to the fifth day. An acute pain of the loins resem- bling a fit of the gravel, in the side like that attending pleurisy, in the limbs resembling rheumatism, or in the stomach accompa- nied with sickness and vomiting, are enumerated by Sydenham as symptoms which he has known to have the effect of delaying the eruption in confluent smallpox. * The salivation sometimes, though rarely, appears in children. Tis- sot says, he lias seen several, scarcely four years of aga, seized with the salivation, while the bowels remained costive. See Ttiasot's Treatise on. the Small-Pox, Apoplexy, and Dropsy. Vol. I. X x sen SMALL-POX. On the second day of the fever an erythematic inflammation^ often appears on the face, and soon spreads over the neck and breast, and in some cases over the whole body. This is the fore- runner of pustules, which begin to emerge from it in the form of small red points, many of which soon coalesce. They sometimes appear in clusters, the intermediate spaces being free from them j at other times many parts, and particularly the face, seem almost covered Avith them. The eruption in the confluent small-pox on its first appearance is sometimes so like that of the measles, that they can only be distinguished by the accompanying symptoms. The pustules form matter sooner in the confluent than in the distinct small-pox ; they are not much raised above the surround- ing parts, nor do they retain the circular form, but even in places where they are not confluent they become of an irregular shape; nor are they surrounded with an inflamed margin as in the distinct small-pox, the spaces between the pustules are pale and flaccid, and the pustules themselves, about the time of maturation, often appear like thin pellicles fixed upon the skin.* On the face, where they are generally most numerous and confluent, they often so run into each other, that almost the whole seems one large ve- sicle, the surface being perfectly smooth. The matter becomes whitish, brown, or almost black, but never thick and yelloAv like that of the distinct small-pox. The lighter coloured the matter, the better is the prognosis. When the pus- tules are of a black colour, the danger is very great. The same may be said of those cases where extravasated blood is mixed with the matter, giving it the appearance of a bloody sanies. The matter of the confluent small-pox has sometimes been so virulent as not only to destroy many of the soft, but even the bony* parts of the face. Themose, cheek bones, palate, fauces, velum pendulum palati, and uvula, have been wholly destroyed by it, and the jaw-bones so much affected that the teeth have fallen from their sockets.t The sAvelling of the face, which only now and then occurs iiv the distinct small-pox, is a constant symptom of the confluent; and in this form of the disease it both appears earlier and rises to a greater height. About the ninth day ofthe eruption, that is, about the eleventh of the disease, the pustules begin to pour out their matter, which hardens on the surface, forming crusts of a brown or black colour, that do not fall off for many days; and are almost always on the face followed by a desquamation which leaves pits. The more * This flat appearance of the pustules in die confluent small-pox has been termed Sessile. By some writers the confluent sraall-pox is termed Variola Sessilis. X See Burserius's Inst Med. Pract and other works on this disease. SMALL-POX. 36i numerous and confluent the pustules are, and the darker their co- lour, the longer they are in disappearing ; and the desquamation is sometimes protracted beyond the twentieth day. It often happens, that although the pustules are crowded on the lace, they are feAv, and even distinct, on every other part of the body. But while the face is loaded Avith those of the confluent kind, the pustules on other parts never have a benign appearance ; they are never circular, raised, nor filled Avith a well conditioned matter, but in this .respect resemble those on the face. In all ■cases of the confluent small-pox however, the pustules on the trunk and extremities are generally rather larger, and mojre pro- minent, than those on the face. Although the fever in the confluent small-pox often becomes more moderate on the appearance of the eruption, yet it never wholly ceases. This remission generally continues till about the sixth or seventh day, that is, from soon after the period of erup- tion till near that of maturation, Avhen it suffers a remarkable ex- acerbation, the commencement of the secondary fever, Avhich often appears with more alarming symptoms than any that pre- ceded it. If coma does not supervene, the patient is distressed with head-ach and obstinate watchfulness, often the forerunners of delirium. The inflammatory affection of the fauces, with hoarseness and dyspnoea, increases, ancl in many cases all the worst symptoms of typhus supervene, and the patient is carried off on the eleventh day from the commencement of the disease including that on Avhich it made its attack. The eleventh day the reader will find frequently mentioned by Sydenham, and other writers, as the most fatal in the small-pox. Such are the appearances of the regular distinct and confluent small-pox. It will be proper to recapitulate the circumstances in which they differ, and point out the manner in which they in- sensibly run into each other, that the means of collecting the prognosis may be placed in a clearer point of view. 3. Parallel of the Symptoms of the Distinct and Confluent Small-Pox. The eruptive fever in most cases at its commencement differs only in degree. It is generally accompanied with those symp- toms which characterize synocha, but in the confluent they are more severe than in the distinct, and the pain and confusion of the head more frequently rise to delirium. In the distinct small-pox we often observe in adults a tendency to sweating. In proportion as the succeeding eruption is about to be numerous, this lendency begins lo disappear, ancl that to purging, particularly in children, to sheAv itself. When the •eruption is about to be confluent, the purging is generally con- siderable, and in the worst cases, the stools are unusually fetid 364 SMALL-POX. «nd sometimes mixed with blood ; hence it is, that Sydenham justly considers a tendency to sweating a favourable, and to purg- ing an unfavourable, symptom In the most benign small-pox there is little affection of the feuces. and no salivation When the eruption is numerous, yet distinct, the affection of the fauces is evident, and often attended with a spitting of thin saliva. In the confluent small-pox the sal- ivation, particularly in adults, comes on early and is generally considerable. In the mildest form of the disease, the eruption seldom appears before the fourth day. If the pustules are about to be numerous, it generally shews itself about the end of the third, if about to be confluent, often on the second, ancl in the worst cases, even on the first day. The eruption in the confluent however is sometimes, though rarely, delayed to the fourth or even to the fifth day ; so that the period of eruption here is less certain than in the distinct small-pox. In the mildest cases, the first appearance of the eruption is that of small red points. In cases where the pustules are about to be numerous, and still more if they are about to be confluent, they are often preceded by a rash on the face, neck, and breast, some- times spreading over the whole body. In the mildest form of small-pox the pustules appear few and distinct; in more severe cases they are more numerous, and often here and there, particularly on the face, in small clusters. In the confluent small-pox they are still more numerous, and more fre- quently appear in this way. In the mildest cases the pustules are considerably raised above the surrounding parts, and are terminated by a point; they are quite circular at their base, and surrounded by a florid margin, which is also bounded by a very exact circle. In cases where the pustules are more numerous, they are less raised and the circular appearance is not so exact and uniform, hi proportion as the number of pustules increase, their elevation is less, and the cir- cumference of the base and margin become more irregular. W hen they are confluent, particularly in the worst cases, the pustules are almost flat, and the circular shape and florid margin nearly or altogether lost. In the most favorable cases, although the matter at first ap- pears colourless, it soon becomes thick, white, opaque, and at length yellow. Where the pustules are numerous, it continues colourless longer, becomes however opaque and thick, though not so much so as in the mildest cases, and whitish ; but seldom assumes the proper yellow colour. In the confluent small-pox it never becomes thick, but changes to a brownish white colour j and in the worst kinds, it is mixed with blood or becomes almost black. SMALL-POX: 365 In the mildest kind of small-pox, pustules cease to come out about two diys after the commencement ofthe eruption. When they are about to be more numerous, they generally continue to make their appearance for a longer time ; and in some cases of the confluent, for three or four days. In the distinct small-pox, matter is seldom observed in the pus- tules before the fifth day of the complaint. In the confluent, it gen- erally appears earlier. In the former, a dark spot, appears on the pustules, they become rough, and pour out part of their matter, very uniformly about the eleventh day. In the cpnfluent. al- though this frequently happens about the same period, yet the pustules sometimes continue fresh as it is termed for a much longer time. Dr. Cleghorn* observes, that it was often the four- teenth or fifteenth day before the confluent small-pox in Minorca became rough on the face ; and on the legs and arms it frequent- ly continued fresh till near the thirtieth day. So that the period of exsiccation, like that of eruption, is less certain in the conflu- ent, than in the distinct, small-pox. In mild cases the pustules fall off about the twelfth or four- teenth day, and are not followed by pitting ; when they are more numerous, they adhere longer, and pitting generally follows. When they are confluent, they are still longer in falling, and pit- ting almost uniformly succeeds them. In the most favourable forms of small-pox, the fever almost en- tirely leaves the patient soon after the pustules make their ap- pearance. Where the pustules are more numerous, a considera- ble remission takes place, but seldom complete apyrexia. In the confluent the remission is less considerable, and in the worst cas- es hardly to be perceived. In the mildest small-pox the patient experiences no return of fever about the seventh or eighth day. Where the pustules are more numerous, he is attacked, about the latter of those days, with the secondary fever; when they are confluent, this fever generally makes its appearance a day or two sooner, and all its symptoms are more alarming. In the mildest small-pox there is little or no degree of fever on the eleventh day. When the pustules are numerous, there is generally on this day a considerable exacerbation of the febrile symptoms ; where they are confluent, such an exacerbation takes place on this day, that it frequently terminates life. In the more favourable cases, the secondary fever is a well- marked synocha, slowly assuming the form of typhus. In the .confluent small-pox, the fever is sooner changed to typhus ; and in the worst kinds of the confluent, the secondary fever is a ty- phus almost from the beginning. • Sec his Treause on the Diseases of Minorqjto 366 SMALL-POX. The most benign small-pox is accompanied with little or no swelling of the face. When the pustules are numerous, but distinct, this happens on or about the eighth day ; when they are confluent, the swelling of the face comes on sooner and rises to a greater height ; the same may be said of the swelling of the hands and feet. Upon the whole, the more any kind of small-pox differs from the simple benign form of the disease, the periods are less cer- tain, the various symptoms generally appear earlier, rise to a gi eater height, are protracted for a longer time, and attended with greater danger. From what has been said it appears, that we may often, before the appearance of the eruption, determine of what kind it will be, since many of the symptoms, characterising the distinct ancl confluent small-pox, precede the eruption. The following, as appears from the foregoing parallel of the symptoms of distinct »nd confluent small-pox, are the principal circumstances which enable us to predict of what nature the eruption will be. When the symptoms of the eruptive fever are moderate and readily relieved on exposure to cold, the eruption will almost al- ways be distinct. When the excitement is more considerable ancl less readily relieved ; when the patient is harrassed with pains of the back, limbs, and loins ; when there is much coma, or any degree of delirium, especially if the fever in other respects also shew a tendency to typhus, we may expect a confluent eruption. A tendency to SAveat in the eruptive fever generally precedes the distinct; a tendency to purging, the confluent. If the affection of v<.c fauces is either not perceived at an early period, or is pre- sent only in a slight degree, the eruption will probably be distinct. W hen tiiis affection is considerable and accompanied by saliva- tion, a confluent eruption may be expected. The method I have followed in detailing the symptoms of reg- ular small-pox, has occasioned some repetition. This appeared to me admissible, in order to place the prognosis, in so impor- tant a disease, in a clear point of view, which cannot, for reasons mentioned in the Introduction, be done without some repetition. 4. Of the Symptoms of Anomalous Small-Pox. It will be sufficient to point out the circumstances in which some of the most remarkable forms ofyanomalous, differ from the regular distinct and confluent, small-pox. One of the most common of the irregular forms of small- pox is that termed crystalline, from the appearance of the pus- tules. At first view it may appear wrong to regard the putrid as a regular, and the crystalline as an anomaloas, form of the dis- SMALL-POX. S6? *ase. When we recollect however that the putrid small-pox, as It has been termed, only differs in degree from the common con- fluent, which from improper treatment, or peculiarity of consti- tution, ever«y day assumes this appearance ; and that neither the distinct nor confkient small-pox are apt to degenerate into the crystalline ; the propriety of this mode of arrangement is suffi- ciently apparent. Besides, the crystalline small-pox is often epidemic, while other forms of the disease hardly shew them- selves.* It is more common however for a few cases of crys- talline to appear while the greatest number of patients labour un- der the regular small-pox. Dr. Rogers divides the crystalline small-pox, in the same way in which the regular has been divided, into distinct, contig- uous, and confluent. But here there is not the same room for such a division ; for although in some instances the pustules are feAver and more distinct than in others ; yet the state of the mat- ter, as well as the appearance of the pustules themselves, does not vary much in different cases % and in all, the danger is con- siderable. The crystalline small-pox makes its attack, like other forms of the disease, with the common symptoms of fever. The vomiting, pain at the pit of the stomach increased on pressure, ancl coldness of the feet and hands, are still the diagno- stic symptoms of the eruptive fever- It is more apt than the regular small-pox to be attended with those symptoms which indicate danger, coma, delirium, prostra- tion of strength, petechia, hemorrhagies, 8cc. ; for although the fever, as in the regular small-pox, is synocha at the commence- ment ; the typhus more frequently sheAvs itself at an early period. The eruption on its first appearance frequently looks well, and even continues to do so for one or two days. The pustules are of a good colour and distinct, producing a considerable re- mission of the febrile symptoms. About the third day of the eruption however, there generally appears a numerous crop of pustules ; which, although in general distinct, are of an irregular shape, seldom appearing circular as in the distinct form of regu- lar small-pox. After the eruption is finished, a considerable remission of the fever takes place, but never complete apyrexia ; and the urine generally remains limpid throughout the Avhole complaint. The distinguishing symptom is the appearance of the matter, which is a colourless fluid that rarely acquires any degree of the puru- lent appearance. As in the regular small-pox, there are now and then interspef- * See an Account of the Epidemic Small-Pox ef Cork, in Dr.Rogers's E*eay on Epidemic. Diseases. S6S SMALL-POX. sed among the pustules some which are empty, or clear and denso having no cavity. Whatever be the appearance of the pustules on their first com* ing out, they soon become pale. They are never indeed sur- rounded ivith the wel'-defined florid margin ofthe regular distinct sm.iil-pox, and the interstices have the flaccid appearance ob- served in the confluent. The period at which the face and head sAvell is more uncertain than in the regular small-pox, and the swelling in a day or two after its appearance is often suddenly translated to the hands or feet. When this happens it has been observed that no salivation takes place. If the eruptive fever runs high, it is often folloAved by a con- fluent eruption, and then the danger, which is at all times con- siderable in the crystalline small-pox, is very great, few escap- ing from this form of the disease ; in which the fever generally soon becomes a malignant typhus. In the worst cases, the face and head either do not swell at all, or only in a slight degree, but instead of the swelling, there is generally inflammation about the eye-lids, lips, or some neigh- bouring part.* The inflammation'sometimes seizes on the en- cephalon, occasioning violent head-ach ancl delirium. In the lat- ter cases traces of inflamma ion of the brain ancl its membranes are generally apparent after death. Even abscesses form in dif- ferent parts of the head, and matter i> sometimes discharged by the ears.t The strong pulse at the temples, while that at the wrist is feeble, mentioned among the symptoms of synochus as denoting a tendency to phrenitis, is a frequent symptom in the crystalline small-pox, and there affords the same inference.^ The crystalline small-pox sometimes proves suddenly fatal be- fore the eruption appears ; more frequently however death is de- layed to the seventh day ; sometimes to the fourteenth, seven- teenth, or even longer. || * Soreness of the mouth and throat, instead of the swelling of the lace, attended a malign.in: sm ill-pox, described by Dr. Cleghorn in his account of the Diseases of Mi < uvea. Solid and empty pustules frequentiy appeared m this epidemic, which was one of the most fatal of which we have any account. f In tiei--.; wu: «* f >~m of small-pox it is not uncommon for abscesses to form m different parts of the body, and recovery seems often to de- pend on the pas being p.-operlv discharged Abscesses'!" RoserTobserves, if the matter is properly discharged. Haller'sDisp. are often favourahle ad Hist. etCur. Mirb. Pert X The inference fr-im -his symptom is the same in all cases of fever. In nervous complaints, a.iitten led bv fever, the pulse is often strong and full at the tem;>ies. whueita, -veakat the wrist, the face at the same time appearing flushed, i:id the eyes freqaentlv inflamed, without denoting any tendency to infl-imunation of the encephalon. || See Dr. Walker's Treatise on the Small-pox. SMALL-POX. 36$ A remarkable form of the anomalous small-pox is that which it sometimes assumes when influenced by the measles appearing at the same time, illustrating an observation made Avhen speaking of contagion, namely, that during a contagious epidemic, almost every disease which appears is sometimes more or less influenced by it. We have an instance of this form of small-pox in the epidemic described by Sydenham, which raged in London in 1670, 1671, and 1672. It appeared while the measles were preA'alent, ancl continued for sometime after they had ceased, gradually becoming milder and more regular till the year 1674, when the measles again became epidemic, ancl the small-pox as irregular and fatal as before. Every case was attended with danger, although the pustules Were not always confluent. But even where these were distinct, the complaint was attended with many symptoms Avhich in the regular small-pox belong to the confluent form of the disease* The eruption appeared on the third day, the pustules were never spherical, and became black sometime before their separation. In some cases, although the pustules were distinct, salivation came on, from which, Sydenham observes, we must infer, that notwith- standing the pustules being distinct, the disease partook more of the confluent than of the distinct small-pox, In confluent cases this epidemic differed more essentially from the regular small-pox. On many places, particularly on ihe thighs, there appeared among the pustules small \'esicles filled with a colourless fluid. When the pellicle forming these Avas broken, the serum ran out, and the parts beneath appeared black and gangrenous.* All died in whom the blisters became gan- grenous. On the eleventh day a white shining pellicle covered the face, which threw out a matter that soon formed a crust, neither yellow like that ofthe distinct, nor brown like that ofthe confluent, small- pox ; but resembling concreted blood, which during the matura- tion of the pustules grew darker, till at last the whole face became almost black; from which the disease was termed, the black small-pox. The eleventh clay was less to be dreaded than in the regular forms of the disease ; in the greater number of cases the patient surviving to the fourteenth and sometimes to the seventeenth clay ; if he escaped during these periods, his chance of recovery was better. Those in whom the blisters appeared, generally died within a few days after the eruption. * Such cases are to be regarded as a combination of small-pox Avith the symptomatic eruption which characterizes tiie vesicular fever. Vol. I. Y y 370 SMALL-PO&. The symp*oms upon the Avhole were more severe than in me regular confluent small-pox, and the eruption on its first coining out had more of the appearance of the erysipelas or measles, so that at an early period, it was only known to be small-pox by attend- ing to the diagnostic symptoms of the eruptive fever. The dis- colouration of the skin also remained longer, and the face was deformed AAith deeper pits. It is remarkable and farther illustrates an observation just made, that towards the end of the epidemic, at which time the dysentery raged, the small-pox was apt to assume the form of this com- plaint. " Operse pretium est et illud adjungcre, quqd, durante hac " omni constitutione qua tarn epidemice seviebant dysenterix; " variola: regimine justo calidiore provocate, per dysenteriam " nonnunquam viam sibi fucerent; quod ne semel accidisse hac- " tenus quidem animadverteram."* We cannot here help remarking the concurrence of the mea- sles, and the unusual fatality of the small-pox, which has been ob- served in other instances. It is an observation even among the vulgar that the small-pox is apt to appear immediately before or after the prevalence of the measles. In such cases however it is not always of a remarkably malignant kind as Sydenham found it.f Another curious observation has been made relating to the symp- toms of these complaints, namely, that if, while a patient labours un- der thesmall-pox, he is seized Avith the measles, the course of the former v> interrupted till the eruption of measles is finished.f The measles appear, lor instance, on the second day of the eruption of small-pox, the progress ofthe small-pox ceases till the measles ter- minate desquamation, and then goes on in the usual way ; and the time from the first appearance of the eruption of small-pox to its termination, is found longer than it ought to be, by the time during which the measles were present. In the third volume of the Medical Commentaries, however, cases are related by Dr. Rainey, in which a concurrence of the small-pox and measles took place without the progress of the former being retarded || Analogous to the foregoing fact, is one mentioned by Dr. Heberden, in Dr. Kirkpatrick's Analysis of Inoculation, namely, that Avhen the small-pox appeared during an epidemic intermittent, if any la- * Sydenhami Opera, sect. iii. cap. 6. De Variol. Anomal. f See the lS4tii and following pages of Sim's Tieatise on EpidemicDis- orders. X See the first volume of Dr. Duncan's Medical Commentaries, &c. || Cases cf this kind 1 have known. SeA eral ai e related in the Medical and Physical Journal. Pechliiiiis, Yc-get observes, svx, a case inwl'di »niall-pox appealed en the light side of the body, and at the jr.me time measles en the left, the line of divide n I ting a jeij ti-diciilai ciu-va through the middle cf the bcdy. This cate is tco txtiacidir.aiy to &aia ijnphcit credit. SMALL-POX 57; "bouring under the feA'er were seized with the small pox, the for- mer ceased till the small-pox had run its usual course, and then went on as before. We meet wiih similar facts relating to other erupti e diseases. Thus Dv. Jenner, in the Continuation of his Observations relating to the Cow-pox, relates a cuse in which the scarlatina was inter- rupted by the appearance of this disease. " But the most re- " markable part of this history is, that on the fourth day after- *k wards, as soon as the efflorescence ofthe cow-pox began to die " away upon the arm, and the pustules to dry up. the scarlatina " again appeared, her throat became sore, and tlie rash spread all " over her. She went fairly through the disease with its com- " mon symptoms." To return from this digression; there is still another form of the anomalous small-pox which deserves to be mentioned. It is met with only in children, ancl seems to be merely the rep;iiiar confluent small-pox considerably modified by peculiarity oi eon- stitution, those only of a debilitated habit of body being subject to it. The patient is attacked with langour and oppression, that con- tinue for some days without considerably affecting the pulse, which is seldom much more frequent than in health, and the tem- perature is not above the healthy degree, sometimes below it. As the symptoms advance, the patient loses his appetite, is trou- bled Avith nausea and insatiable thirst, becomes drowsy and of'.m comatose. On the third day a few pustules generally come out, but they soon disappear, and the coma increasing termi;;aies life in a few clays. There is still another set of symptoms which deserve the name of anomalous, yet do not constitute a distinct form of the disease. They are apt to occur when the course of the disease is disturbed by improper treatment or any other cause. When the sweating becomes profuse, the swelling of the face either does not appear, or only in a slight degree, the skin re- maining flaccid and the interstices of the pustules pale, although t le eruption is distinct ; and had not the SAveat been profuse, the complaint would have proved mild. In such cases indeed, the pustules themselves generally look well, are red and raised, and even remain so after death. It now and then happens that the SAveat, after flowing freely for some time, suddenly ceases, which is also a very dangerous accident. In many cases neither cordials, external vvarnub, nor any other means, arc capable of recalling it. The patient is sei- zed with sickness, anxiety, extreme restlessness, often delirium, passing the urine frequently and in small quantity, and some- times expires in the space of a lew hours. 572 SMALL-POX. It noAv and then happens in like manner in the confluent small- pox, that the salivation suddenly ceases ; and unless this acci- dent is immediately folloAved by the swelling of the face ancl hands, the patient generally dies. In the confluent small-pox, Sydenham remarks', both the salivation and sAvelling are necessa- ry ; if either fails, the patient is in danger. Where the salvation does not wholly cease, but the saliva becomes so thick that it cannot be spit out, the patient is sometimes threatened with suf- focation ; ancl the deglutition is often so impeded that a liquid .taken into the mouth is apt to fall into the trachea, and is thrown out by the nose Avith much coughing. When a thickening ofthe saliva is attended Avith coma, the patient generally dies on the eleventh day. This state of the saliva however may be present in some degree without indicating much danger, A total suppression of urine sometimes comes on about the height of the disease, even in the distinct small-pox, especially if the habit be full and the patient in the vigour of life. Although a diarrhoea is to be regarded as a favourable symp- tom in the confluent small-pox, yet it sometimes becomes so pro- fuse as considerably to modify the disease ancl add to the unfa- vourable prognosis. "\\mere this or other debilitating causes, such as sudden exposure to cold after the hot regimen has been employed, unseasonable blood-letting, Sec. have existed; it some- time happens that the eruption, or SAvelling ofthe face and hands, or both, recede ; and then the danger is very great.* It sometimes happens that after the exsiccation ofthe pustules, a neAV crop shews itself; and, on the other hand, that the fever with all its peculiar symptoms appears without any eruption at all. It is asserted by Erank, Burserius, ancl others, that in the latter case the patient is as secure against a second attack of the disease, as if the eruptidh had made its appearance. There are some observations however which contradict this opinion. In the fourth volume of the Memoirs of the Medical Society of London, ■Mr. Kite relates tAvo cases in which inoculation produced the usual suppuration in the part inoculated, ancl at the usual time the patient sickened, but no variolus eruption folloAved. Both pa- tients were again inoculated fourteen days after the first inocula- tion. One of them had the disease in the usual way and in a mild form ; the other remained unaffected. I shall have occasion to mention many of the more remarka- ble deviations from the ordinary course of the disease, in speak- of the means to be employed Avhen such accidents occur. The small-pox, especially the confluent and irregular forms of the disease, is apt to leave behind it a variety of troublesome consequences. Most of those Avho survived the irregular small- * See Sydenham's chapter entitled, Variola; Regulares, p. Mo. SMALL-POX. 373 pox of Minorca, Dr. Cleghorn informs us, remained blind, con- sumptive, or lame with caries of the bones, ulcers, &c. Some- times a grangrcnous erysipelas of the limbs, or apoplexy, has su- pervened ancl proved fatal. Blindness from a pustulary affection of the cornea is not uncommon, more rarely the hearing is de- stroyed, and the voice is sometimes lost. The palpebral, the sides of the nares, and even those of the throat,* have grown together. All kinds of small-pox leave behind them a predisposition to inflammatory complaints, particularly to rheumatism, ophthalmia and visceral inflammations. On this part of the subject the rea- der may consult the 582d and following pages of the fifth vol. of Haller's Disput. ad Hist, et Cur. Morb. Pertinentes, and the third vol. of Frank's Epitome dcCurand. Horn. Morb. SECT. II. Of the Causes of the Small-pox. THIS is one of the diseases which have only made their ap- pearance in Europe in modern times. There is no mention in the writings of the Greek or Roman physicians of any disease which can be supposed to have been the small-pox ; ancl we are unable to determine how long this disease has been knoAvn in other parts of the world, orAvhcre it first made its appearance. The Arabian writers are the earliest Ave are acquainted with, who mention it. Both Rhazesand Avicenna treat of the small- pox. Of these, Rhuzes is tho oldest. The oldest' writer on the small-pox mentioned by Rhazes [Aahron] resided at Alexandria when it was besieged by the Saracens in 640 of tlie Christian sera. There is no distinct mention of the small-pox earlier than this. The most prevalent opinion is that it Avas brought to Alexan- dria from the East, having been known in many parts of Asia, particularly in China, from much earlier times. Many circum- stances hoAvever tend to contradict this opinion. There is reason to believe that it raged among the Abysinians, Avhen they besie- ged Mecca in the year 569 ;t from Avhence it probably travelled into Egypt with the Mahometans, spread Avith them along the northern parts of Africa, and accompanied them when they pas- sed over into Europe.J: The opinion that the small-pox was first brought into Europe by the crusaders is unfounded, as Dr. Woodville has met Avith it, under the name Variolar, in manuscripts of the Harlean and * See Vogel De Cog. et Curand. Morb. t See Dr. Woodville's History of Inoculation. X See Friend's History of Medicine from the days of Galen to the be- ginning of the loth century. S74 SMALL-POX. Cottonian Collections in the British Museum, which bear evi- dence of having been written before the year 900. There can be little doubt hoAvever, that by means of the crusaders the small-pox Avas more generally disseminated throughout Europe.* It is mentioned by British Avriters as early as the 13th century, but at what time it was introduced into this island is not knoAvn. In America it was unknown till carried thither by the Europeans. This imperfect history of the small-pox, although there Avere no other facts on the subject, is sufficient to prove, that it arises from a peculiar contagion, the presence of which, or of the con- currence of causes which first gave it birth, is necessary for the production of the disease. An opinion has prevailed indeed respecting the small-pox, as well as most other contagious diseases, that besides the presence of the contagion, a certain state of the air, which authors term an epidemic constitution of the atmosphere, is necessary to ren- der the complaint prevalent ; an hypothesis, once maintained by the best writeis, but noAVSo obsolete as hardly to deserve discus- sion ; which I had occasion to consider when speaking of conta- gion. The only fact which tends to support the opinion is, that the small-pox and other contagious diseases often cease to rage while there is reason to believe clothes, furniture, 8cc. to be still impregnated Avith the contagion, and Avhiie many still remain ca- pable of receiving the disease. Why this should happen it is impossible to say in the present state of knowledge ; if Ave are however to frame an hypothesis to explain it, it must be one more consistent with other facts than the theory of the epidemic con- stitution of the atmosphere. The fatality of the small-pox soon led to the employment of a variety of means with a view to obviate its effects. It is com- puted that one of six dies who receive the small-pox in the natu- ral way, and that about the eighth part, and in some places many more, of the people of a country where the casual small-pox is prevalent, fall a sacrifice to the disease. " The celebrated M. " De La Condamine computes that in France one in ten of all who " are born dies of the small-pox. Dr. Rosenstein, who wrote an " excellent Treatise on the Diseases of Children, shews, that " every tenth boy and every ninth girl dies of it in Sweden, ac- " cording to the accurate reports of the commissioners appointed " to make the inquiry. In London, the births are to the deaths " by the small-pox, as six and a fourth to one ; in Manchester, as " six ancl a half to one ; in Liverpool, as five and a half to one; " in Chester, as six and two thirds to one."f * In some of tlie northern parts of Europe, which have little intercourse with the rest, the small pox wasnotknoAvn, it is said, before the beginning of the present century. t See the Introduction to Dr. ITaygarth's Sketch of a Plan te e«termi- Bate the casual Small-pox, &c. SMALL-POX. 375 At certain times the Small-pox proves much more fatal. 0£ thirty-seven ill of the worst kind of small-pox, attended by Bar- oTi Dimsdale while in Russia, thirty-five died. One of the most evident ancl earliest means adopted to mode- rate the fatality of small-pox, was removing the sick from all in- tercourse with the healthy. A convenient place was appointed for the reception of the former, who were not again admitted in- to society till they had been well for some lime.* In the High- lands of Scotland, when a child is seized with a very mild kind of small-pox, those in the neighbourhood expose their children to be infected by it. We noAv know, that the nature of the small- pox depends less than might a priori be expected on its being re- ceived from the mild or confluent forms of the disease, so that little advantage can accrue from the practice. They practice another method however, which must be atten- ded Avith better success. Worsted threads wet with matter are tied round the wrists, by which the disease is frequently induced. Dr. Rush observes indeed, that he could not induce the small- pox by rubbing the matter on the entire skin, from which it is probable, that the practice ofthe Highlanders only proves sucess- ful when the Avet worsted threads produce a degree of excoriation. Such is the rudest mode of inoculation, the most effectual of all the means which have been devised for preventing the mortality of the small-pox. The prejudice against inoculation among the lower ranks has hitherto in a great measure prevented the beneficial effcts which it is calculated to produce ; for the inoculation of a single child often infects a Avhole neighbourhood ; so that it is alleged, and in many places even appears from the bills of mortality, that upon the whole the deaths by this disorder have rather been in- creased than diminished since the introduction of inoculation. This has induced some to propose rejecting the operation, and endeavouring entirely to prevent the disorder, by the means em- ployed for checking the progress of contagious diseases. This plan however promises but little. It is impossible that such a disease as the small-pox can be entirely eradicated from so im- mense and populous a country as Europe ; ancl who would propose to banish it from this island while it raged on the Continent, with which we every day have the freest intercourse ? nay, were it * The Calmucks, who first received this disease from the Russians, have thepiactice of carrying thoie seized with it into the woods and leav- ing them in huts with some proA isiens. These who survive are i.et per- mitted to have intercourse with the other inhabitants, till they have been Avashcd, and have remaii.cd Avell for a ccnsiderable lei gth of time. '1 he Hottentots, who it is said first received the disease frem nmc Dutch tai- lors, set guards around the place where it appears, and <»vciy ptri»uiA\h». attempts to escape is inunediately Uiot. *\7& SMALL-POX. even possible at once to extirpate it from Europe, would it not be immediately received from the Asiatics ? Intercourse among na- tions is noAv more frequent than in ancient times. It would be impossible to exclude so infectious a disease from Europe, if it raged on the coasts of the Levant and other western parts of Asia* Unless therefore Ave can extirpate the disease from the vvhoje World, plans of extirpation are vain. It is urged indeed that the plague has been banished from most countries of Europe, and that were the proper means employed, we might in like manner banish the small-pox.* But can the circumstances of the tAVo complaints be compared? Was the plague ever so general throughout Europe as the small-pox? The former is confined to a few spots. The Avhole world know when it sheAvs itself, and avoid communication with the places where it rages. It visits chiefly large ancl populous cities, and is for the mOst part effectually banished by the removal of croAvd- ed and dirty streets, and by having a cautious intercourse with the few places which it still visits, and from which, were the proper means employed, it is more than probable it might also be ba- nished. Others assert, that it is better to suffer the returns of the small- pox, such as it appeared before the introduction of inoculation, than thus constantly to preserve it amongst us. To this it may be ansAvered, that admitting that the deaths by the small-pox have not been lessened by the introduction of inoculation, it is evident that this is oAving to the operation not being sufficiently general. What haA-e been the effects of inoculation, under proper regula- tions? At Chester it is found, that the mean number of deaths bythe small-pox are 14 annually. Before the institution of a society there for promoting inoculation, the mean number of deaths were 63 annually. It is probable indeed that the time is not very distant when, in many places at least, inoculation will be general, and then comparatively the small-pox will hardly deserve the name of a disease ; for by a moderate computation, of those who have been inoculated while in health, properly treated, and in whom no other complaint supervened, not above one in 150 died.t According indeed to many, particularly late, observations, the proportion of deaths is much less. It has been computed that at Chester only one in 208 died of the inoculated small-pox. Of 416 patients inoculated at Liverpool, one* only died. In the * See Vogel's Praticct, Acad. De Cog. et Cur. Morb. f ^ th,e accounts of Drs. Jurin, Monro, and Dimsdale. Dr. Monro'* Treatise in particular deserves attention. It contains an answer to cer- tain questions put to him by the dei'.-gates of the faculty of medicine at Pans, concerning the inoculation of small-pox. It is entitled an Account of the Inoculation of Small-Pox in Scotland, by Alexander Monro senior. SMALL-POX. 377 London Small-pox and Inoculation Hospital, of the last 3000, on- ly one in 600 died of the inoculated small-pox.* Reflecting on these circumstances, instead of endeaA'ouring to eradicate the small-pox,t it should be the aim of physicians to render inoculation and the proper treatment as general as pos- sible. They will thus most effectually check the fatality Avhich has hitherto attended this disease. It is of great consequence therefore to be well acquainted with the practice of inoculation. The circumstances respecting inoculation which demand at- tention may be arranged under three heads. 1. The choice of proper matter, ancl the mode of performing the operation. Inoculation should be made as effectual and at the same time as easy for the patient as possible. When the op- eration is more severe than necessary, we deter people from sub- mitting their children to it. When clone carelessly and too slight- ly, it often fails of producing the disease, Avhich both puts the pa- tient to unnecessary.trouble and destroys his confidence in the op- erator. 2. The state of the patient at the time he is inoculated, and his treatment before and after the operation till the commence- ment of the eruptive fever. They must be such as afford the best chance of the complaint appearing in the mildest form. 3. Cautions to prevent the introduction of the casual small- pox. In the first place, of the operation, and the choice of proper matter. The mode of performing the operation at present generally adopted is extremely simple. A pustule is opened, and the point of a lancet dipped in the matter. This may either be used immediately when received from the pustule, or it may be allow- ed to dry, and Avhen about to be used, moistened Avith warm water. The matter may be kept for a number of years without losing its power. It is the custom in some parts of the East to keep it for a great length of time, where inoculators often boast of using mat- ter collected by their grand-fathers. Nor does it seem necessa- ry to be particularly careful in defending it from the air. Some experiments haA'e been made to determine whether or not expos- ure to the air is capable of so altering the properties of variolous matter, as to prevent its producing the disease. " It has not been * Sec Dr. Woodville's reports respecting the inoculation of tiie Variolsc Yaccinx. [• Sec the observations on the Cow-Pox at the end of this section. Vol.. I. Z z 37$ SMATX-POX. " in my power," Dr. Currie observes in Dr. Haygarth's Sket'cH* of a Plan to extcrmmate the casual Small-Pox," to attend to the " experiments you suggested, but I have tried whether variolous " matter exposed to the air, and indeed to the wind, for thirty " days, can communicate the disease by inoculation, and the re- «f suit has been as I expected ; the disease was communicated " Avith the usual certainty and success. I inoculated' three pa- « tients at the same time ; in one the eruptive fever appeared on " the fifth day ; in another on the seventh ; and in the third on " the ninth....My opinion is, that I shall be able to inoculate Avjth " the same matter, diluted in flie same way,^ many months or K perhaps years hence. The reason why variolous matter long " kept has sometimes failed in producing the disease, I apprehend " to have been that the dried matter was not previously reduced «-' to a state of fluidity." Many practitioners however prefer re- centfluid matter.* It appears from some trials, that matter witich has been long kept may produce inflammation and gene- ral derangement of the systemr and yet fail in producing the small-pox. The point of the lancet armed with the matter is introduced 6bliquely beneath the cuticle, so as to wound very slightly, and occasion little or nofloAV of blood.t In withdrawing the point of the lancet, it is proper to press the wound with the finger, that the parts in contact with the matter may wipe it off the lancer, and thus secure the success of the operation. The wound is so slight that bandages, or plasters of any kind are unnecessary. Such is at present the most approved and simple mode, of per- forming inoculation. Others have been practised, Avhich put the patient to much uneasiness without answering the purpose any better4 Some do not introduce the lancet, but only scratch the skin ; and Mr. Mudge has proposed a method, which he thinks succeeds with more certainty than that generally in use, namely scratching the skin, and rubbing it with a bit of spunge which has absorbed some variolous matter.|| With this part of the subject, which rather comes under the province of surgery, I shall not detain the reader. Although it belongs to surgeons to settle all disputes concern- ing the best modes of performing operations, in some chxum- * See the obserA-ations of Baron Dimsdale and others. t It is of consequence to guard against a considerable flow of blood, as this often washes out the matter, and thus prevents tiie success of the operation. X See an account of the old modes cf inoculating by large incisions, and by vesication, in Dr. Kirkpatrick's Analysis of Inoculation. U The reader will find an acconnt of this method, and the instrument with Avhich he performs the operation, in his Treatise on the Inoculation: of Small-Pox* SMALL-TOX. sri •itances ills the physician's part to determine when it ig propefr to recommend them. It is therefore necessary for him to be ac- quainted with what has been determined respecting the preference to be given to particular kinds of matter, that he may not find himself at a loss when all kinds, or only one kind, of matter caa be procured. Many prefer the matter in a crude state, that is, before it asr sumesthe purulent appearance ; and the success which attended •the practice of Sutton, a celebrated moculator in Essex, was by some ascribed to his using the matter in a crude state.* Dr. Dimsdale preferred the matter taken from the inoculated part during the eruptive fever; and some inoculators prefer it at a still earlier period, supposing that the more crude the matter is, it will produce the disease with the greater certainty .f From the following experiment however it would appear, that matter in a Very crude state >yiU sometimes fail to produce the disease.—- '* Messrs. Langworthy and Arscot, surgeons at Plimpton, in the " spring of 1776, inoculated forty patients, of Avhich number thir- " ty were inoculated with crude matter from the arm of a young " woman, five days after she herself had been inoculated with " concocted matter, which produced in her pretty smart feyer, *' and a sufficient mimber of pustules ; the other ten were ino- « culated with matter of another kind, which I procured in " a concocted form from a pustule of the natural small-pox. " The arms of all the forty patients took the infection, and the " latter ten, after the eruptive fever, had the small-pox in the " usual way. Of the other thirty, though the infection took " place on their arms, so as to inflame them considerably, and to " produce a very large prominent pustule with matter in it on each M of them ; yet not one had any eruptive fever, or a single subse- " quent pustule on any part of the body ; but about the eighth, in -" some the ninth, and in others the tenth, day, the inflammation "began to disappear.; and about the twelfth or thirteenth, the " pustules on their arms scabbed off. It is to be remarked too, u that the matter which was in those pustules, having been used •c to inoculate others, produced on them exactly the same appear- " ances, unattended also with either fever or small-pox." " It was thought worth while to inoculate all those patients xi with well concocted matter, in order to see whether or not the " effects of the crude matter had so altered their constitutions as " to render them incapable of afienvards having the small-pox, " The whole were inoculated with well-formed matter, and all of " them had tlie small-pox in the common form." In the malignant kinds of small-pox the matter always has a * See Mr.' Chandler's Treatise on Inoculation. t A surgeon informed me, he had known the crude matter succeed \fhere the maturated had failed to produce the disease. «38» SMALL-POX. crude appearance. It is found however as certainly to produce the disease as the matter of the most benign; and what is re- markable, generally at least, produces it in as mild a form ; tho mildness or roaUgnity of the small-pox seeming little i£ at all to depend on the state of the inoculating matter. From the worst kinds of matter, the most favourable forms ofthe disease have been produced, and from the best matter, the most malignant The choice of what is termed good matter, therefore, is not of such consequence as at first sight it may appear. Even the daring ex- periment of inoculating Avith matter taken from a dead body,1* has been practised with safety. But although we were better convinced than we aref of the safety of inoculating with bad matter, yet the general prejudice against it would make a prudent practitioner choose that of a be- nign kind. Where this cannot be procured, and the patient is evi- dently in danger ot the casual small-pox, we should not hesitate a moment in recommending inoculation from any kind of matter that can be procured. . Nor does the quantity of matter introduced seem to have much, if any, effect in determining the mildness or severity of the dis- ease ; an hypothesis on which some attempt to explain the ben- efit derived from inoculation ; the disease, as has been observed a thousand times, proving equally benign or otherwise whether a larger or smaller quantity be introduced. Some practitioners indeed, Burserius, Dr. Fordyce, and others maintain «ft oppo- site opinion, and consider the quanty of matter employed in in- oculation a point of much consequence. Burserius observes, that those inoculated by many incisions have the disease in a worse form than those who have it from one incision. And Dr. Un- derwood in his Treatise on the Diseases of Children says, he has observed that when several inoculations have failed, in whicli case we may also suppose a greater than usual quantity1 of varied lous matter introduced, the disease proves more severe than iii other cases. "1:1 How far such observations arc accurate, it. is difficult to. say. It is certain that different modes of inoculation have been practi- sed, in Avhich very different quantities of matter were introduced, and all have produced an equally benign form of the disease. " In the case of small-pox," Dr. Cullen observes, " a considera- " ble difference in the quantity of contagious matter introduced " has not discovered any effect in modifying the disease." * See an Essay by Mr. Chandler. Mr. Keate also inoculated with matter from a dead body, but from an accident no inference respecting its safety can be drawn from his experiment. See Dr. Pearson's obser- vations in the 19th volume of the Medical Commentaries. X Many experienced practitioners maintain that the choice of good matter, though not of such importance as once supp Led, has some ef- fect in insuring the mildness of the disease. SMALLfPOX. 381, When inoculation fails in producing the disease, the inoculaj* ted part nevertheless sometimes inflames and suppurates, as in cases Avhere the disease is about to follow ; .and it as remarkable) that the matter produced in such cases ig as fit for inoculation as that.taken from a person actually labouring under tho disease.* It has even been found, that if a person, who lias already. Lad the small-pox,- be inoculated and the Avound suppurates, the,mpti 4er it produces is capable of giving the diseaso.t ,♦ ■.:.< rtnv . Although it sometimes happens, that'in'those who have5 rir5! had the small-pox the inoculated part inflames.aiid s^pnfKTftes without producing the disease, yet this is comparatively fare; When the part jnffames ancl small pustules are seen surround- ing the incision, Ave may with great certainty expect thediseaso*- A considerable and early inflammation in the part inocnlat'ecTis favourable ; paleness and flaccidity the reverse ; and Dr. Dims- dale even observes, that he has found some degree of stilfness' and pain in the axilla to foretel a favourable disease. The matter of small-pox must be applied to a wound, in, order to induce the complaint. It was observed above, that Dr. Husft could not induce the small-pox by rubbing the matter on the en- tire skin ; ancl Dr. Cowel, the same author informs us, gave a ne-» jgro girl some variolous matter mixed with a dose of physic wiiioik produced no sensible effect. •, .>.-rrf 2. Of the state of body.in which inoculation has proved most successful ; and the treatmentof the patient before and afteB the operation, till the appearance of the eruptive ferel\i ' It has always been considered one of the chief advantages of in- oculation, that by means of it we are enabled to induce the small- pox at a proper age, at a time when the patient.is not labouring under any other disease, and after the body has been'prcpared'Jor receiving it in. tlie mildest form. The subject therefore divides itself into two parts : the state ofthe person about to be inoculated with respect to age and habit; and the preparation necessary, by exercise, diet, or medicines, before and after the .operation* As the vievv of inoculation is'to prevent the casual/small-pox, it should.be performed early in'life.' But the tender constitution of infants, for some time after birth, renders the slightest complaints dangerous. Many have'tberefore laid it down' as a rule, that chil- dren ought not to be inoculated under two years qf age. Very : * Mr. Davidson, in .the third volume of the Medical Transactions, mentions two instances of children in av!k mi the disease did not appear till after the second inoculation, the first inoculation only producing inffai% matToh and suppuration of the part; from which however matter Wai taken that produced all the'lisuai symptoms of smaH-pox. f Thu, avc are informed by Dr. Ib,>i, Dr. \Yay ascertainedbfkn ex- periment made on himself. m SMALL-POX. young children sometimes in the inoculated, much more fre* 9MALVP^ ** Whatever the time of life be, we should if possible avoid ino- culating tiiose labouring under other diseases. Dentition, espet cially if attended with troublesome symptoms, is a sufficient rea£ son to delay inoculr on, when it can be delayed with safety., Children with large heads,, particularly those who have beer* threatened with water in the head, generally have .the .small-pox: in a dangerous form, and are consequently bad subjects forinaQUt toon. Dr. Dimsdale mentions two cases of this kind* in which, although the eruption was favourable, coma supervened and both) patients died. A similar accident happened under the manage' ment of Mi*. Charles Maitland, on the introduction of Inoculation. into Scotland, which procured the operation a very t>ad reception" in that part of the island. In short, inoculation should be perform- ed while the subject is in all respects in good health. There are some diseases however which shew Iktle or-no ten- dency .to. increase the severity of the small-pox. -*A tendency to acrophula, or even its presence,, is not found to increase the dan- ger of the small-pox. Djv Heherdpn,#»Dr. Kirkpatrick's Analjk sis of Inoculation, mentions the case of a boy dying oi* scrophula* who bad the small-pox in a very mild ifflrjB* Dr. Cullen remarks^! that several diseases of the pkin are equally innocent when compli- cated wkh small-pox j and justly observesj " They are the diseases ". of the febrile kind, or those ready to induce or aggravate a febrile * state, that especially give the concurrence that is most dangerous. " with the small-pox." Dr. Dimsdale did not wish to inoculate those labouring under any acute disease, or much debility, and he avoided inoculation Avhen any epidemic prevailed. v*" It may be observed upon the whole however, ihat theihabits. of body in which the small-pox is most apt to prove unfavourable are; far from being thoroughly ascertained. The sum of all that we knoAv Avith certainly seems to be, that the disease is apt to be se- vere in the debilitated, the plethoric, and those labouring under febrile diseases. In some families it is particularly unfavourable, instances of whichT know, where it is impossible to detect the cause of this peculiarity. Pregnant women are bad subjects, for inoculation, for although the disease generally appears in them in as mild a form as in oth- ers, it is apt to be followed by miscarriage. This ma/ sometimes be owing to uie foetus receiving the disease from the mother* of which there are many well-authenticated instances ; and it has sometimes happened, that Avhere the mother had but a very feAV pustules, the child has been found almost covered with them;" When the mother is near her time before she is seized with the •mall-pox, as in a case mentioned in the 18th volume ofthe Medical Commentaries, the eruptive feter sometimes appears in th& child a day or two after birth. The reader will fitid cases suppciru ing these observations in the I9ih volume of trfti" Medical*«on> S84 SMALL-POX: mcnhuics, in the 155th and following pages of the 2d volume of BurseriUs's Institut. Med. Pract. and other works on this disease. Burserius'mentions Cases from different authors, io which the foe- tus had the disease, from the mother being exposed to its conta- gion, although, it did not produce the small-pox in her ; Vo- gel also observes, that the foetus maybe infected with the fmqil-pox without the mother having it; so that there may be sonie'ejanger in pregnant women exposing themselves to the con- tagion .of ^mall-pox, although they have had the disease. It is al-, rr.o»'t unnecessary to observe, that the patient is as secure from a second attack of the disease by having it before, as he is by hav- ing it after, birth. • Dr. Pearson says, that inoculating about the sixth month of pregnancy is seldom fatal to the mother, but often kills the foetus. ln^bout tAventy cases of the casual small-pox in the last months of pregnancy, it proved fatal lo above three-fourths ofthe women, and a still larger proportion of the foetuses. - The occurrence* of the menses during the small-pox has been regarded as dangerous, but many observations, as Camper* ob- serves, prove this opinion to be unfounded. A difficult or very profuse menstruation is certainly unfavourable. Some constitutions are incapable of having the disease in any form. It is even said that there is a whole family at Genevaf who are incapable of having the small-pox. Others do not receive the disease at one time, however freely exposed to its contagion, even though repeatedly inoculated, and yet afterwards receive it merely perhaps from approaching those labouring under it. " 1 know an old nurse," Dr. HuxhamJ ob- serves, " and one apothecary, who for many years attended per- " sons and a great number too in the small-pox, and yet never had " them ; nay many that have industriously endeavored to catch " the infection by frequenting the chambers of the sick, have done " it without effect, ancl yet some of these persons some months or " years after have been seized with the small-pox." It has been computed that only one of 38 escape the small-pox when pro- perly inoculated or otherwise fairly exposed to the contagion. It has long been a prevalent opinion that a certain regimen previous to inoculation and even medicines are indispeusible. The person to be inoculated is put on a spare diet, desired to use regular exercise, ancl to take various medicines, generally mercurial or antimonial, for some days before the operation, and * See a Treatise by Camper, entitled, Les Avantages de l'lnoculaticu et la meillure Mcthodc de l'adniinistrer. f Sec Dr. Ilaygarth's Sketch, £:c. - tSrfc'Huxhan.VTie^tisc-en Fevers, Srnali-Pox, and Peripneurnoity, SMALL-PO*. 585 till the commencement of the eruptive fever. That these pre- cautions by their antiphlogistic tendency are sometimes of use, and that it tnaf be proper to delay feeding children with animal food till after they have had the small-pox, as Dr. Cullen recom- mends, we have every reason to believe. Many are of opinion however that when the patient is in perfect health, and when the only tendency of a change in diet and a course of medicines is that of inducing a state in some measure different from health, they are not only useless, but hurtful. " Gatti," Dr. Baker* observes, ** who was sometime ago much employed in inoctila- " tion at Paris, declares himself an enemy to any general plan " of preparation. In all the Levant," he continues, " where u the natural small-pox is as fatal as elsewhere, and where you " may find old women who have inoculated 10,000 without an « accident, the only inquiry is, whether or not a person is pre- " pared by nature. All that is considered is, whether the breath " be sweet, the skin soft, and whether a little wound in it heals " easily." It is improper however in all cases to neglect every means of preparation. In full habits the eruptive fever often runs high, although this consequence is not so certain as some have sup- posed it. The reader will find cases, (a very striking one is related by Mr. Mudge) in Avhich patients of the most plethoric habit paid no attention whatever to regimen, either before or after inoculation, and yet had the disease in a very mild form. He will even find in Dr. Percival's Essays, that the bark, so generally allowed to increase the inflammatory diathesis, has- been given, between inoculation and the eruptive fever, to re- move an intermittent, without any bad consequences. From a few facts however no general conclusion can be drawn. We should endeavour to observe a proper medium, neither reducing the strength by unseasonable evacuations, nor inducing the dis- ease on the plethoric, without using precautions to moderate the ensuing feier. Tlie preparation recommended by Dr. Rush* can never prove hurtful. It consists merely in the use of mild cathartics and a vegetable diet. He reprobates the use of mercurials, to Avhich he attributes the glandular swellings, loss of teeth, and weak habit, which often succeed the small-pox. We are led to believe hoAvever, from a great variety of observa- tions, that a prudent use of antimonial and mercurial prepara- tions, previous to inoculation, tends to insure the mildness of the disease. For a proof of this the reader may consult Dr. Gale's Dissertation on the Inoculation of Small-Pox in America, Dr. Andreivs's Treatise entitled The Practice of Inoculation impar- * See Dr. noAv Sir George Baker's Treatise on the Inoculation of Small-Pox. f Sec his Medical Inquiries and Observations. Vol.. I. A a a ^3-6 SMALL-POX. tially considered, &c. Dr. Baker's Account of the Suttoniau' IMqde of Inoculation, Mr. Chandler's Treatise on the same sub- ject, ancl Baron Dimsdale's Treatise entitled The present Mode of Inoculating the Small-Pox. The following was the mode of preparation Avliich Dr. Dims- dale thought most successful. If the patient was debilitated, he endeavoured to restore the strength ; if plethoric, to correct this habit He made it a rule to clear the stomach and intestines, ancl generally confined the patient to a milk ancl vegetable diet for nine days before inoculation, during which he purged with Claij- bcr's salt ; the night before each purge he gave a close of calo- mel, ancl a small quantity of tartar emetic. The exhibition of the powder and cathartic was generally repeated three times, but the treatment Avas varied according to the state of the patient. After inoculation, when the inoculated part remained pale, whlcji gave reason to dread a severe disease, he gave the mercurial ancl antimonial powder every night ; and, if it did hot prove cathartic, joined with it Glauber's salt or an infusion of senna with manna and tincture of jalap. It is to be recollected, that the habit of body may be conside- rably affected by particular states of the weather: that in which rheumatic and other inflammatory diseases are epidemic, and that in which complaints of a contrary tendency, malignant fe- vers, Sec. prevail. In the one case, evacuations Avill be more fre- quently serviceable ; in the other, more generally pernicious! In choosing the season for inoculation, the spring is generally preferred, in order to avoid the extremes of heat and cold, and because the epidemic small-pox is generally mildest in this sea- son. It is also observed, that the casual small-pox is milder about the vernal equinox, than when it appears earlier.* Dc., Dimsdale, although he preferred the spring, thought there Avas little objection to inoculating either in summer or Avinter, provi- ded the patient was protected from the extremes of heatj and cold. The autumn bethought the most exceptionable, on ac- count of the putrid small-pox being most common at this season. Attention to the time of year however, provided there be no ma- lignant epidemic raging, is not of much consequence, since the inoculated small-pox, with proper treatment, is a mild disease at all seasons. Situation seems often to have more effect in modifying the small-pox. At a distance from large towns it is less apt to appear of the putrid and anomalous kinds, and the more crowded and dirty a city is, the more apt the small-pox is to prove unfavoura- * See tiie 5th vol. cf IvIcCicr.l Observations and Inquiries. X Dr. Cleghorn remarks, that he has cbrerved the virulence of the small-pox L.cicaLC Avith the heat of the weather. SMALL-POX. 3o7 ble. Dr. Walker* ascribes the unusual severity ofthe small-pox in the city of Cork to the following circumstances. " In the city h of Cork, from its situation upon the edge of the great Atlantic " Ocean, the Avinds three parts of the year blow from west and " south west, ancl drench the inhabitants in the warm and Avatery " vapours detached from the surface of that Avide extended sea. " The city is situated in a deep valley, built on islands, and sur- " rounded by brances of the river Lee. There are considerable *' marshes to the east and Avestof it. Quantities of animal offals " occupy the streets, and particularly the close confined alleys " and lanes. At the season endemical diseases rage most, there ■*' arc a great number of slaughter-houses in the north ancl south " suburbs; vast pits containing putrifying blood ancl ordure, u Avhich even corrupt the northern blasts which blow down upon " the city ; vast quantities of animal offals used by the common " people in the slaughtering seasons, rendered more pernicious " by ihe quick transition from diet of another kind and different u n'ature."t We cannot doubt that inoculation, by enabling us to induce the small-pox at a time Avhen the state of body is most favourable, is alone a matter of considerable importance ; yet we cannot agree with those who, believing that all the advantages of inocula- tion may be attributed to this, subscribe to the opinion of Dr. Huxam Avhen he observes, " I am persuaded if persons reguLr- " ly prepared were to receive the variolus contagion in the na'.u- " ral way far the greater part would have them in a mild man- « ner/' It appears, from a variety of facts, that the advantages of inoc- ulation are owing neither to the, preparation of the patient, nor any other circumstance which we can detect, but to some pecu- liar disposition in the animal economy, Avhich will ever perhaps re- main a secret; fcr what has been said of the casual small-pox be- ing received by the lungs, and on this account proving more dan- gerous, is merely hypothetical.!: The other opinions on the sub- ject rest, if possible, on a still worse foundation. It appears, from what vvas said above, that none of the advantages of in- oculation is to be ascribed to the quantity or quality of the matter employed, as some have thought ; and with regard to the opinion of the body being peculiarly disposed to the disease when the small-pox is taken in the natural Avay, and the poison on this ac- count operating more violently, a moment's reflection sheAvs its invalidity, since very few Avho have not had the complaint will at * Sec his Treatise on the Small-Pox. X Tiie malignant small-pox is frequently observed to precede the plague. See Sailer's Disput. ad Hist, et Cur. Mob. Kit. vol. v. p. 557. X This opinion seems to receive some support from the prac ice of the Chinese, who inoculate by putting tiie dry scales of the small-pox hite the nose, and among whom die disease is far from being favourable. 588 SMALL-POX. any time escape it if freely exposed to its contagion. It is un- necessary eA'en to recapitulate the different opiuions on this suh> ject. The reader -will find another, though not a more success- fol attempt, in the 2d vol. of the Collect. Soc. Hafn- Obs. 9 th, . With respect to the treatment of the patient after the opera- tion till the commencement of the eruptive fever, it issimUar to the treatment previous to the operation, and may easily be collect* ed from Avhat has been said. Animal food and fermented liquori should be avoided, unless there is much debility. Cold, fatigue, and every other cause of fever is highly pernicious. Gentle lax- atives are to be continued as the state of the body requires, which should be open; and the continued exhibition of small doses of mercurials ancl antimonials tends to ensure the mildness ofthe dis- ease, although they are certainly far from being necessary in tho generality of cases. Where there is any thing unfavourable* such as a plethoric habit, an unusual deficiency of inflammation in the inoculated part, 8cc. they ought never to be neglected. Dr. Dimsdale believed the excellence ofthe Suttonian mode of inoculation to consist in the three following circumstances: the last of Avhich we shall presently have occasion to consider at length1. 1. The preparation by antimonials and mercurials. 2. Inoculat- ing with recent fluid matter. 3. The free exposure to cold and the laxative course in the eruptive fever. The most important part of the subject remains to be consi- dered. 3. The cautions to be employed in the practice of inoculation, have been too much neglected; to which alone Ave owe the me- lancholy reflection, that the fatality ofthe small-pox has hitherto been little, if at all, diminished by the introduction of inoculation1 into Britain. " When any one is about to be inoculated, where the small-pox is not already prevalent, all who are accustomed to come to the house, or live near it, should be made acquainted with it, that those who have not had the disease may either be inoculated, or avoid intercourse with the patient and his attendants. It is the duty of the inoculator to insist on this alternative, and to offer inoculation gratis to the poor. Various plans have been proposed with a view wholly to banish the casual small-pox. Dr. Dimsdale inoculated all the inhabit- ants of a village who had not had the small-pox in one day, having previously removed those who from bad health, or other causes,* were improper subjects for inoculation. And when this can be done, he thinks it should be repeated every five Mr six years. This plan hoAvever is but ill calculated to banish the casual * See what has been said respecting tlie habit, age, &c proper for inoculation. SMALL-POX. »a* small-pox. It would be impossible to secure the inhabitants against its introduction during the intervals of inoculation- No Avriter has bestowed so much attention on this subject as Dr. Haygarth.* The following are his regulations for preventing the casual small-pox ; and from his OAvn observations as Well as those of his correspondents, there is reason to believe, that could they be enforced, they would be found sufficient for the purpose. It is the opinion of Dr. Haygarth, and most of his correspondents, that clothes, furniture, &c. cannot imbibe the contagion of small- pox from an infected atmosphere, ancl therefore only communi- cate the disease when the matter adheres to them. Should future experience contradict this opinion, some addition to the folloiving precautions will be necessary. There is also reason to hope, on the other hand, that experience may prove some of them to be superfluous; if this should not be the case, it is to be feared that they are too various and troublesome to be generally adopted. " 1. Suffer no person who has not bad the small-pox to come into " the infectious house. No visitor, who has any communication " with persons liable to the distemper, should touch or sit down " on any thing infectious. " 2. No patient after the pox have appeared! must be suffered " to go into the street or other frequented place. Fresh air must u be constantly admitted by doors and windows into the sick " chamber. « 3. The utmost attention to cleanliness is absolutely necessa- " ry: during and after the distemper, no person, clothes, food, u furniture, dog, cat, money* medicines, or any other thing that " is knoAvn or suspected to be bedaubed with matter, spittle, or « other infectious discharges of the patient, should go, or be car- « ried, out ofthe house till they be washed, and till they be suffi- " ciently c\posed to the fresh nir. No foul linen or any thing "else that can retain the poison should be folded up, or put into " drawers, boxes, or be otherwise shut up from the air, but must "be immediately thrown into Avater ancl kept there till washed. " No attendants should touch what is to go into another family " till their hands are washed. When a patient dies ofthe small- li pox, particular care should be taken that nothing infectious be " taken out of the house, so as to do mischief. " 4. The patient must not be allowed to approach any person " liable to the distemper till every scab has dropped off; till all " the clothes, furniture, food, and all other things touched by the " patient during the distemper, till the floor ofthe sick chamber, * See his Treatise, entitled A Sketch of a Plan to exterminate the ca- sual Small-Pox from Great-Britain, ike. X Should it not be, after the appearance of tlie eruptive fever, since the ilisease is infectious from its commencement? S9« SMALL-POX. " and till the hair, face, and hands, haA'e been carefully Avaslicd. " After every thing has been made perfectly clean, the doors,* " windows, draAvers, boxes, and all other places that can retain in- " fectious air, should be kept open, till it be cleared out of the " house." When the casual small-pox has actually appeared, then the va- rious means for checking the progress of contagious diseases, enumerated when speaking of typhus, must be had recourse to. The separation of the sick from the healthy is particularly to be attended to, for Avhich purpose a proper place* should be appoint- ed at a small distance from towns for the reception of the poor, who are seized with the disease. Care should be taken to bury the dead privately, and to use proper means to free from the con- tagion those who recover before they are permitted to return to their houses. Many have placed confidence in some of the medicines men- tioned Avhen speaking of the means of checking contagious dis- eases, for defending against the contagion of small-pox. Mercury and musk have been particularly recommended, but nothing of this kind is to be depended on. The various means belonging to this bead are to be regarded as less efficacious in defending against the contagion of small-pox, than that of typhus. General inoculation will be found the best means of preventing the spread- ing of the small-pox. It would be fortunate if Ave could discover as easy and effectual a method qf cutting short th j progress of other malignant fevers. By taking care that none should be exposed to its contagion but those who have had the disease or submitted to inoculation,! we place an almost insuperable barrier to the pro- ress of the small-pox ;| nor is it necessary that those who have * There should be a permanent building for this purpose in the neigh- bourhood of every considerable town, without which it is almost impossible to prevent the casual small-pox among the lower ranks, on account of their refusing to have their children inoculated. f A proposal has lately been made in Scotland to render inoculation general, by publishing a set ot" simple regulations respecting inoculation and the treatment of inoculated small-pox, and endeavouring, Avith the assistance ofthe clergy, to induce parents to inoculate their own children. The inoculated small-pox is generalfy so mild a disease, and the pror/jr mode of treatment in it so simple, that the danger of constantly introducing the casual small-pox appears to be the principal objection to this plan. If the cow-pox, a disease Ave shall presently have occasion to consider more particularly, be found, as we have reason at present to believe, ca- pable of securing the«constitution against the attack of small-pox, there will not be the same objection against inoculating for it in this way, as it is not contagious. It is even a milder disease than the inoculated small-pox. X Well authenticated cases indeed are on record of the small-pox hav- ing attacked the same person a second time or cfrener; such cases how- ever are rare. There are instances in Hurserius's Inst. Med. Pract. at- tested by the best authority, of the small-pox having appeared a second er even a third time in the same persan. In the 2d vol. of the Collect. Sod SMALL-POX. 3»I not had the disease should remain at a considerable distance from the infected; it is sufficient that they remain at the dis- tance of a few feet, and be careful not to touch any thing Avhich has been in contact Avith the sick, or is besmeared with any secre- tion from their bodies. It is even the opinion of some, that the contagion of small-pox cannot be applied through the medium of the air, and although it appears from a variety of facts that this opinion is erroneous, it is certain that it is very rarely con\reyed by the air to the dis- tance once supposed. The reader will find sufficient proofs of this in the experiments of Dr. Ryan.* Tlie small-pox, contrary to an opinion once prevalant, is infec- tious from the first attack of the eruptive fever. It has already been hinted, that it has not beeu accurately ascertained when a person, who has laboured under this disease, is perfectly free of the contagion. It is asserted by Burserius, that if the disease runs its ordinary course, the patient is incapable of communica- ting it forty days after inoculation, that is, rather more than thirty days after the commencement of the eruptive fever. The eruptive fever generally makes its appearance at some pe- riod from the seventh or eighth to the tenth or eleventh day after inoculation. In 810 inoculated patients 5 19 became fei'erish be- fore the ninth day, 291 on or after the ninth day, that is, the fever in the proportion of more than five to three comes on before the ninth clay. It is observed of the inoculated small-pox, that the earlier the eruptive fever appears after inoculation, the more fav- ourable is the disease.t In the casual small-pox the fever seldom appears before the ninth day after infection. It is alloAved that the fever never appears earlier than the fifth day, ^whether from in- Hafn. there is a well-attested case of the same kind; and a very extraor- dinary one, quoted from Borelfius by Rosen, in the 5th vol. of Haller's Disp. ad Hist, et Cur. Morb. Pert. A woman had the small-pox seA'en times, and died of it at the age of 118. Mr. Kite, in the 4th vol. of the Mem. of the Medical Society of London, relates several cases, in which there could be no doubt of the small-pox appearing for a second time; and Mr. With- ers, in the same vol. mentions an instance cf a person labouring under the small-pox, who many years before had had i:is f;xe deeply pitted and seamed by it. In Dr. Jenner's Continuation of Facts relative to the Variol. Vaccinae, Dr. Mills relates his own case. He laboured under the small- pox a second time from inoculation. * See Dissertations sur les Fievres Infectieuses et Contagieuses, par M. O'Ryan, D. M de lTSniversitc de Montpelier, &c. There is an account of his experiments in Dr. Haygarth's Sketch, &c. It has been observed, that infants in particular are lets liable to the casual small-pox thin has been supposed. Dr. Underwood, in his Account of the Diseases of Chil- dren, says, that infants in particular are nou.pt to have the ciKeuse in the natural way, and that he has known them sleep in the same cradle with those under it without being infected by them. X Sec Dr« Dimsdale's Treatise. Q9fl SMALL-POX. oculation or not. It has been known to be as late of appearing as the 16th, 17th, or even 23d day.t It is a fact of importance, Avhich has been ascertained by a great variety of observations, that after the commencement of the eruptive fever, whether the complaint be the inoculatedior casual small-pox, there is no clanger of increasing its severity hy the freest exposure to a second infection. It even appears, that the patient might be exposed without danger to the contagiojj of small-pox as soon as inoculated, provided we could be certain that the inoculation was about to prove successful ; the presence of the complaint in consequence of the first application of thq contagion obviating any consequence to be apprehended from a .succeeding infection. In the transactions of a society for the improvement of medi- cal and surgical knowledge, a*mong other obsecvations Dr. l-'or- dyce remarks, that if a person be successfully inoculated, ancl a few days after again inoculated, the fever will appear when tho wound from the first inoculation suppurates, ancl will not be in- creased Avhen that from the second does so. There is reason to believe indeed, that were a person inoculated immediately after being infected in the natural Avay, the appearance of the inocu* lated Avouid prevent that ef the casual small-pox ; and that the patient, having been infected in the natural way previous to in- oculation, would not eA'en increase the severity of the disease* The reader Avill find a variety of observations in'the Avorks which have been mentioned, in confirmation of these remarks, parti* cularly in the different accounts of the Suttonian,method of in- oculating. Mr. Sutton did not hesitate to expose his patients in the freest manner to the contagion from the moment they were inoculated. Such are the principal circumstances to be attended to in ths practice of inoculation. We probably owe this, like many other useful inventions, to chance. It has been ascribed to the Circas- sians, ancl Avas first employed by them, it is said, as a means of preserving the beauty of their women. From other obse.r,if^| tions it would appear, that inoculation originated in Africa. Mr. Colden, in his Letter to Dr. Fothergill on the Malignant Sora Throat, says, that he found, from conversing with several Ne- groes from Guinea, that inoculation had been long practised it* their country, nearly in the same manner and at the same time of life as in Europe ; and Mr- Mungo Park, in his travels into the interior of Africa, found it so. But the truth is that inoculation has been practised not only in various parts of Asia and Africa, but even in some parts of Lur rope, for an unknown length of lime ; nay it is even certai»i j Seethe conclusion of Dr. Haygarth's Sketcb,_£cc. page 539,54S, aivi SMALL-POX. 395 y other parts of the horse, is capable of occasioning the disease in cows.* Another circumstance which has occasioned much difference of opinion respecting this disease, is, that in some cases it has hqen attended with eruptions. Dr. Woodville says, that about three-fifths of his patients had pustules on different parts of the body, resembling those of the small-pox. The appearance of pustules Dr. Jenner is inclined to attribute to the small-pox mat- ter having been used instead of, or mixed with, that of the coav- pox ; ancl observes, that all his correspondents Avho met Avith small-pox-like pustules, had the cow-pox matter from the Small- pox Inoculation Hospital in London. There are several circumstances however which lead us to question the justness of this opinion. Dr. Woodville, in order to determine the effects of mixing the two matters, made the following experiment : " Twenty-eight p..tients Avere on the "same day inoculated Avith the matter of cow-pox and that of " small-pox mixed together in equal quantities, in order to try " Avhich would prevail, or if it were possible- to produce a hybrid '.' disease by an union of both. The result Avas, that in more " than one-half of the patients thus ii-.oe>.;k»ied, the local affection u distinctly assumed the characters ol the cow-pox. In the oth- u ersit more resembled the small-pox, but in none of them was " there much indisposition or many pustules. " At the request of Dr. Jenner, I transmitted to him in Cio-jces- " tershire, some of the cow-pox matter from the patients then " under my care, which he used for the purpose cf inoculation. »l After a trial of it lie informed me, thut the rise, progreuj, and * See Dr. Jeruier's first publication above alluckd to. 59* SMALL-POX. «c termination of the pustule created by this virus on the arm, -** Avas exactly that of the true uncontaminated cow-pox. The " matter sent was taken from the arm of Ann Bumpus, Avho had ■" 310 pustules, all of which suppurated, yet with the matter of " this stock Dr. Jenner inoculated tAventy, and another gentleman *' in the same county 140 persons without producing any pustules *l which maturated. " This fact would appear to confirm an opinion entertained by v Dr. Jenner in his second publication on the variola; vaccina;. " He seems disposed to attribute the pustules Avhich so often at- *' tended this disease in London and its vicinity to some peculiar ■" influence of the town air. But ofthe cases which I have stated, " several Avere those of patients who Avere inoculated eight miles " distance from London, yet these patients in the proportion of " about one in five, had an eruption. And at a small village still "'further from London, eighteen persons were inoculated with " simitar matter, in all of whom it produced pustules." There are also some other facts Avhich Avould induce us to be- lieve, that the eruption isnot the consequence of any admixture of variolous matter, but peculiar to the coAV-pox, for even those pustules Avhich maturate do not run the same course Avith the pus- tules of small.pox. Mr. Jukes, surgeon at Stourport, avIio has been extensively engaged in the inoculation of cow-pox, has fa- voured me Avith some very pertinent remarks, which his accura- cy of observation permits me to quote with confidence. The matter he used Avas procured from Dr. Woodville. With res- pect to the eruption, he observes, " Several of my patients this 41 spring have had pustules, few of which haA'e come to suppura-. 4i tion,; those that did, and which were well characterised, Avere *' of shorter duration than the small-pox pustules." From this it appears, that pustules occasionally appear in other parts of the country as well as in the neighbourhood of London, but that their duration, if it be found uniformly such as in Mr. Jukes's pa- tients, Avill be a sufficient diagnostic betweenthem and small-pox pustules. At other times, Mr. Jukes, although inoculating with the matter originally from the small-pox hospital, has not met with pustules in any of his patients. " I inoculated eleven chil- dren," fie observes, u twelve months ago, none of whom had pus- tules." Comparing these different observations, we should be inclined to believe, that a peculiar eruption belongs to the cow-pox, the appearance of Avhich is determined by some peculiarity in the sit- uation or season, which avc cannot at present detect. Future ob- servations however must determine respecting the nature of this eruption. The great point being admitted, that the coAV-pox secures the constitution against the si..aii-po.c, the next questions cf impair SMALL-POX. 399; fance respect the prognosis and the contagious nature of the cow* pox. On these heads there is less difference of opinion. Respecting the prognosis, Dr. Jenner observes that the cow- pox is never fatal ; and the experience of all, (with the exception of Dr. Woodville) who have Avritten on the disease, in this res- pect agrees Avith Dr. Jenner's. Dr. Woodville, in his reports of a Series of Inoculations for the Var. Vacc. mentions the case of an infant at the breast, in whom the disease proved fatal; it had about 80 or 100 pustules ; the eruption came out on the seventh, and it died on the eleventh day after inoculation. It was carried off by epileptic fits, which first appeared on the seventh day. The cow-pox does not appear to be attended with any particular danger in pregnant women.* Dr. Woodville found, from an ex- periment made on a large scale, that in cow-pox,-the matter from the mildest cases, upon the whole, produces the mildest disease ; ancl the result of this experiment is confirmed by other obser* Tations.f Dr. Woodville is also the only writer who considers the cow* pox as ever contagious. When the disease produces pustules, he observes, it may be taken by infection ; he saw two cases in which the disease was received in this way ; in one the eruptioa was confluent and the disease severe ; in the other it was mild.. It is certainly very rarely contagious-. Dr. Jenner observes, that it is not even communicated by sleeping with those labouring under it. Dr. Pearson^: and others make similar observations. Mr. Kelson, in the paper just alluded to, observes, " I selected ** about forty people in our Avork- house, and inoculated half of " them, some in both arms,- and fixed them to sleep with those " who had not had it; but in- no instance was it communicated to; " the others. I broke the pustules and frequently made them "smell the parts, but to no effect." It is probable that the matter of coAV-pox may undergo such a change by keeping that it shall be incapable of exciting the dis- ease, but it appears from a variety of observations that it is not changed by passing through different constitutions. Whether the matter is taken from the cow, or from the human subject in- oculated from the coav, or has passed through a variety of consti- tutions, the disease is still the same-U * See Dr. Marshall's observations in Dr. Jenner's Continuation, Sec. f See tlie observations of Mr. Kelson in the Medical and Physical Jour- nal. In the different numbers of this work the reader will find a ^V"*/ of papers containing much information respecting the cow-pox ; which is tlie more valuable, as it comes from different quarters and from people wholly unconnected with each other. % See Dv. Pearson's Inquiry concerning the History of the Cow-Pox, See* ij See Dr. Jenner's Continuation, &c. *Q0 SMALL-POX. Inoculation for the coAV-pox, as far as I can learn from those* employed in this practice, more frequently fails than that for small-pox, and more frequently the inoculated part produces a troublesome ulceration. Dr. Woodville remarks that he never saw the part ulcerate. With most inoculators this has been a fre- quent accident, and the treatment of the inoculated part there- fore has demanded some attention. In Dr. Jenner's first publica* tion, he advises us, after the constitution is affected, to destroy the pustules av ith unguentum hydrargiri nitrali, or a more speedy caustic. But in his last publication he observes, " In the early " part of this enquiry, I felt far more anxious respecting the in- " flammation of the inoculated part than at present ; yet that this " affection will go on to a greater extent than could be wished, is " a circumstance sometimes to be expected. As this can ba " checked or even entirely subdued by very simple means, I see *' no reason why the patient should feel an uneasy hour, because " an application may not be absolutely necessary. About the " tenth or eleventh day, if the pustule has proceeded regularly, " the appearance of the arm will almost to a certainty indicate " whether this is to be expected or not. Should it happen, notli- *' ing more need be done than to apply a single drop of the aqi:a " lythargyr, acetati upon the pustule, and having suffered it to " remain tAvo or three minutes to cover the efflorescence sur- " rounding the pustule Avith a piece of linen dipped in the aqua " lythargyr. compos. The former may be repeated twice or " thrice during the clay, the latter as often as it may feci agree- " able to the patient." As far as we are acquainted Avith the cow-pox, we have reason to believe that there is no danger of communicating other disea- ses along with it. And Avith respect to preparation Mr. Kelson obserA'es, " I never thought it necessary to give a dose of physic *' either after or before inoculation." The small-pox is not ahvays a security against the cow-pox. " Although," Dr. Jenner observes,* " the susceptibility of the " virus of the cow-pox is for the most part lost in those Avho have <; had the small-pox, yet in some constitutions it is only partially " destroyed, and in others it does not appear to be in the least di- *4 minished." The matter of the cow-pox from the human sub- ject produces the disease in cows. The variolous matter doc» not produce the small pox in them. * See his Continuation, 8ce. SMALL-POX. 4*1 SECT. III. Of the Morbid Appearances on Dissection in those who die of the Small-Pox. IN those who have died under a load of pustules, the nares and inside of the cheeks are often found covered with them, and the teeth are besmeared with a thick viscid saliva. Pustules are fre- quently observed on the upper, very rarely on the under, part of the tongue, which is better moistened Avith saliva ; the palate is often covered with them ; they also frequently occupy the more external, very rarely the internal, parts of the meatus auditorius. The maxillary, frontal, ancl other sinuses of the face are free from any morbid appearance. The cellular substance of the face, as well as of other parts of the body, especially Avhere the swelling is most considerable, is distended with a serous fluid as in anasarca. On removing the cranium the dura matter appears perfectly sound, but the vessels of the brain, as in most other cases where coma is a frequent symptom, appear more turgid and filled with a darker coloured blood than usual, ancl a greater quantity of se- rous fluid is found, particularly towards the base of the brain, " Circa infundibulum, integra ilia arachnoidex A-agina qux nervos P tertii paris, adsitasque cartes concludit, saccum aqua plenum « referebat."* In other i spects the brain is generally sound. On examining the parts situated in the neck, the oesophagus is found free of pustules, even where the pharynx is loaded with them ; or if any be observed in it, they are towards the upper part. The state of the larynx and trachea is often very different. These with the bronchix as far as their third division are some- times more or less loaded Avith pustules, from which, and the state of the nares, we readily account for the dyspnoea and cough which frequently attend this disease. It sometimes happens however even in the worst forms of the disease thai the wind-pipe is free from pustules. Tissot says he has dissected some so cov- ered with pustules that there \\cs scarcely room fcr one more, without finding any pustules in the larynx or trachea. The tra- chea is sometimes lined Avith aAvhitish crust Avhich is easily sep.<- rated, and the secretion from the bronchix is noAv and then tinged with blood. The fluid of the pericardium is also sometimes tinged with blood, ancl small particles like coagulated blood broken down noAV and then appear floating in it. The surface of the heart has been found rougher than Usual, and polypi are sometimes found in its cavities. It is doubtful if any of these appearances be e&sentially * See Cottunnius de Sede Variolarum, p. 22. Vol. I. C c c 40J SMALL-POX. connected with the disease. With respect to the last, it is a com* mon appearance after death, whatever be the complaint of which the patient dies. The lungs have often a darker appearance, and their moisture is more copious than usual. When no inflamma- tory affection has supervened, they are in other respects sound. The form ofthe thorax has been observed considerably affected by enlargement of some of the abdominal viscera ; this seems to be merely accidental. The various parts, as the mouth, pharynx, larynx, trachea, 8cc. which are sometimes covered with pustules, are now and then in the worst cases affected with gangrene. There are but few morbid appearances in the abdomen. In the stomach there is sometimes found a thick whitish matter, which also frequently besmears the oesophagus, but this is a common appearance of mucus when it has lain in these cavities for a considerable length of time. In examining bodies we often meet with morbid appearances which cannot be regarded as con- nected with the disease of which the patient died, as they are not observed in perhaps one of 50 cases. Thus in those who die of the small-pox, the liver is sometimes enlarged, sometimes soft, at other times hard and gritty, noAv and then hydatids are found in it. The state of the bowels also varies ; worms, for example, or traces of inflammation, are sometimes found in the stomach and intestines. None of these appearances throw any light on the ratio symptomatum) nor indeed seem at all connected with the disease. What principally demands our attention in the abdomen is, that pustules are never found on any of its viscera. Some have asserted the contrary, but it appears probable from the observa- tions of Cottunnius that they had mistaken small lymphatic glands for pustules. He dissected forty bodies in the presence of several people, without observing any pustules on the stomach or intestines. " Did variolous pustules," Dr. Walker remarks, u invest the external membrane of the lungs, liver, stomach or " intestines, and pass through the common stages of inflamma- K tion and suppuration, we might expect a reguiar course ot K complaints more urgent and distressing, th.n Avhat occurs on « the surface of the body ; but we never find this to be the case." It appears then that variolous pustules never attack the cavi- ties of the body, except those to which the air has free access ; as the npse, mouth, trachea, the larger branches of the bron- chia^, and the outermost part cf the meatus auditorius^ It has also been observed in cases of prolapsus ani, that pustules very frequently attack that part of the gut which is exposed to the air. Cottunnius allegesthatpustules appear only on tiiose parts which are exposed to the ahy because moisture prevents their appear- SMALL-POX. 403 *nce ; and in confirmation of this opinion, he observes that if the eye-lids be kept moist by Avet bread from the first attack of the disease, pustules never appear upon them, ancl by the s.-me means, he alleges, pustules may be prevented on other parts. This opinion however is invalidated by the fxtus in utero being subject to the variolous eruption. The seat of the pustules is neither the true skin nor the cuticle, hut the mucus which lies between them. The author just men- tioned made frequent dissections in order to determine this point. " Quolies pustulam incipientem dissecui, vidi cuticulam eleva- " tarn ad pustulx formam, cutis corpore, intacto, et tumoris im- " muni."* The seat of the pustules, a question at one time much agitated, is thus very accurately ascertained ; but this knowledge has not hitherto improved the treatment of the disease. SECT. IV. . Of the Treatment of Small-Pox. FOR the sake of perspicuity I shall divide the treatment of small-pox into that of the Distinct and that of the Confluent forms of the disease ; or rather, I shall consider at length the mode of treatment in the former, and afterwards point out the circumstan- ces in Avhich the treatment of the Confluent differs from that of the Distinct. And farther, to avoid confusion I shall refer to the end of this section, for the means to be employed when those symptoms which have been termed anomalous appear, which will prevent interruption in laying down the general plan of treat- ment. 1. Of the treatment of the Distinct Small-Pox. It was soon observed that the appearance of the eruption in •small-pox generally brings relief, and from this circumstance very umvarrantable inferences Avcre drawn, which for a long time influ- enced the practice in this complaint, and, it cannot be denied, greatly increased its fatality. Eecause the eruption Avas generally attended with a remission of the symptoms, it Avas inferred, that the more copious the eruption, tlie more relief it Avould bring. Every means tending to promote the eruption were therefore employed, and Avhatever tended to check ii was deemed pernicious. By external Avarmth and stimulating medicines, physicians endeavoured to support tlie fever ; while evacuations and Avhatever else tended to moderate excitement, Avas carefully shunned. A very extensive experience has now unfolded the tendency of ♦ Cuttunnius de Sede Var. p. 202. 404 SMALL-POX. these maxims ; and established in their stead others of a very dif- ferent nature. So far from the most copious eruption bringing most relief, the relief is always most complete, when the eruption is most scanty ; so that instead of supporting the excitement, that the eruption may be copious ; the indication in the eruptive fever, which in the distinct small-pox is always a synocha, is to moderate excitement, that the pustules may be as few as possible. All that Avas said of this indication in speaking of the treatment of synocha, is nearly applicable to the case before us. The chief difference between the treatment of the eruptive fe- ver of the distinct small-pox and the treatment of synocha aris- ing from other causes, is, that in the former, the means for dimin- ishing excitement must be more vigorous in proportion to the excitement, than in the latter. In common synocha, Avhich is succeeded by typhus, a liberal use of antiphlogistic measures is seldom warrantable. In the eruptive fever of the distinct small-pox, on the contrary, where the synocha is not succeeded by typhus but terminated by the appearance of the eruption, the same degree of excitement warrants more vigorous antiphlogis-i tic measures. Besides in synocha, it is not only dangerous, but no advantage is to be expected from reducing the excitement, unless very con- siderable. In the eruptive fever of the distinct small-pox, and we shall afterwards find in most cases of the confluent also, it is not merely safe, but the best effects are to be expected from it, the severity of the ensuing disease being generally proportion- ed to the degree of excitement which prevails in the eruptive fe- ver. *' The good or bad management of the eruptive fever," Dr. Nisbet* justly observes, " in most habits, stamps the ex- " tent and future progress of the disease, perhaps I may venture " to say the very nature ofthe pock." " It is probable," says Dr. Cullen, " that the measures taken for moderating the eruptive fc- « ver and inflammatory state of the skin afford the greatest im- " provement which has been made in the practice of inocula- [• tion." Nay the very effects which we dread from evacuations in the common synocha, may be the consequence of avoiding them in the eruptive fever of small-pox ; for wherever the eruptive fever runs high, the secondary fever is apt to supervene ; and this in spile of all Ave can do often degenerates into an alarming typhus. It is not to be inferred however from what has been said that the use of antiphlogistic measures and particularly evacuations cannot be too free. Here, as in all other cases of increased ex- citement, Ave are not to overlook one of the most valuable max- ims in medicine, that the excitement is to be diminished with a? little expense of strength as possible. * See tlie Transactions of the Newhaven Society. SMALLPOX. 19S Such are the principles afforded by experience for conducting the treatment of the eruptive fever of small-pox when it is a syn- ocha. It will be necessary to take a more particular vieAv ofthe several means employed at this period. In the practice of inoculation, it appears from what was said above, a light diet for sometime previous to the appearance of the ehjptive fever is proper, except in very debilitated habits. Alter the commencement of this fever such a diet becomes still more indispensible. It should be as diluent and cooling as possi- ble. Some advise abstaining from all aliment but fresh acessent fruits, at this period, if the excitement be considerable. Whey mixed with acids has been regarded as the best drink, milk has also been warmly recommended by Rhazes and others. M. De Lassone bestows the most extravagant encomiums on it. He particularly recommends it in the confluent small-pox with a de- coction of parsley roots, which he thinks the only articles of diet necessary. Milk he found particularly serviceable when the diar- rhoea was profuse, ancl for moderating the pustulary affection of the fauces We must always make a large allowance in reading the encomiums bestowed on a favourite remedy. On comparing together the observations of a variety of Avriters we shall find rea- son to believe that provided the diet in this case be mucilaginous, diluent, and refrigerant, it is of little consequence Avhat articles jcompose it. To such a diet it is proper in almost all cases to add other means of diminishing excitement. FeAv medicines tend more to diminish excitement in idiopathic fevers than emetics. When the symptoms are at all considerable, they are particularly useful in the eruptive fever of small-pox, especially when the stomach is loaded, as often happens in this complaint. At the commencement of the eruptive fever, emet- ics, Rosen* remarks, are recommended by all. They are never io be omitted, he observes in another place, unless contraindicated by the presence of gastritis. An emetic has been regarded as particularly useful at the commencement of the casual small-pox, from the opinion that the contagion is received by the stomach. It is too severe a remedy to be generally employed in so mild a disease as the inoculated small-pox. The class of medicines which have been termed refrigerant are of more general use. Of these, nitre and saline draughts given in the state of effervescence, are esteemed ihe best ; but the most useful of the neutral salts in the eruptive fever of small-pox are those best calculated to produce a cathartic effect. I shall afterwards have occasion to speak more at length of the use of cathartics in the small-pox ; it is enough at present to ob- cerve, that the sulphate of soda or any other cathartic salt, re- * Haller's, Disput, ad Hist, et Cur. Morb. Teit. vcL t. 406 SMALL-POX. peated at intervals, so as to support a moderate catharsis, forms an essential part of the treatment of the eruptive fever. The bowels are apt to be costive, and costiveness is particularly unfa- vourable in the small-pox, and especially in the eruptive fever. Much purging hoAvever is not necessary but hurtful in mild eases; which is admitted by Dr. Walker and others, Avho make a very liberal use of cathartics in the most alarming forms of the disease. In the distinct small-pox the repetition of cathartics is to be regulated by the degree and obstinacy of the symptoms of increased excitement, particularly the strength and hardness ofthe pulse. This Ave shall find cannot be said of all cases of the con- fluent small-pox. Boerhaave, Mead, Tennent, and others, have insisted on the advantage of mercurial cathartics in the small-pox. Dr. Fowler in particular, in his Inaugural Dissertation, which was Avritten after he had been sometime engaged in practice, speaks in the highest terms of mercury in this complaint. When it is given so as gently to affect the mouth, the disease, he maintains, is aa certainly rendered mild as Avhen it produces catharsis. Mercury, he asserts, renders even the mildest cases more mild and of shorter duration. It often, according to Dr. Fowler, renders the casual smull-pox as mild as the inoculated, and almost always milder than might have been expected. He confesses indeed, that the small-pox has sometimes proved severe in those under a course of mercury,* but observes, that a few cases cannot be adduced as an argument against a remedy generally successful. The ac- knoAvledged tendency of mercury to obviate the inflammatory di- athesis is in favour of Dr. Fowler's observations. Whatever cathartic we employ, the occasional use of cooling clysters is ahvays useful when the excitement runs high. It is remarkable that Sydenham made little use of cathartics in the small-pox, which tended to confirm a prejudice against them, at the commencement ofthe disease, that prevails in some places even to this day. Sydenham howeA'er very generally recom- mended another evacuation, the propriety of which is now called in question in 99 cases of a 100. He made a very free use of the lancet, and in this practice many of his successors have persevered. " Si vel minime suspicari " liceat," says Sydenham, " variolas mox erumpentes, e conflu- « entium genere futuras esse; utile prorsus erit ut, non solum " sanguis quam primum mittatur, sed et emelicum propinetur ob " rationes alio in loco fuse dicendas." Huxham also frequently had recourse to venesection in the small-pox, although he admits the impropriety of recommending it in certain cases in which Sydenham believed it useful. These will afterwards be consider- * Cases of this kind are mentioned by Dr. Fordyce. SMALL-POX. 40T ed; in the mean time let us endeavour to ascertain when blood- letting is to be employed in the distinct small-pox. It is an observation with a few exceptions universally applicable, that blood-letting is only to be recommended when the effects ex- pected from it cannot be procored by other remedies. Of all the means employed by the physician it is the most dangerous. There b no disease Avhich tends more directly to impair the powers of life ; and in the most dangerous cases it is often a doubtful point whether the disease, or the blood-letting which relieves it, is most to be dreaded. It is true indeed, that in most cases of unimpaired vigour, a moderate loss of blood is not attended with danger. But in the strongest its frequent repetition is ahvays to be feared, and a pru- dent physician, as he cannot with absolute certainty foresee the course of almost any disease, and still less what new diseases may supervene, will choose to reserve so poAverful a remedy, in case symptoms should appear that render its exhibition neces- sary. One of the first maxims in the treatment of febrile diseases is to save the patient's strength as much as possible, that our prac- tice may have sufficient latitude, if I may use the expression ; when it is cramped by a debilitated habit, the danger is always great. I shall have many opportunities of illustrating these ob- servations. What practitioner has not seen cases prove fatal, be- cause the patient was too weak to bear the loss of a few ounces of blood ? In the present case then we are to enquire when advantage is to be expected from blood-letting, which cannot be procured by less debilitating means. The question is very easily answered, if it be admitted that diminution of excitement is the only effect to be expected from blood-letting in idiopathic fevers ; which is evident, as far as I can judge, from what Avas said of blood-letting when considering the treatment of intermitting and continued fe- ver ; or if the reader does not deem this sufficient, let him tako the trouble to compare together the facts there alluded to, or to be found in the various works on the disease we are considering. This is not one of the many points in medicine concerning Avhich, facts are Avanting ; it has been sufficiently ascertained by a very ample and fatal experience. ^ If then the diminution of excitement is the only object Ave haA'e in view, shall we unnecessarily reduce the strength by blood-let- ting, while safer measures will produce this effect? If exposure to cool air or a mild cathartic will sufficiently diminish the ex- citement, what need is there for venesection ? We are not, says Burserius, from the appearance of one or two symptoms indicat- ing blood-letting, at once and without consideration to have re- course to this remedy in the small-pox, unless si:ch symptoms be constant and vehement, and such as leave no room to doubt of the -408 AM ALL-POX. propriety of blood-letting; for blood-letting may often be deferred or omitted Avithout running any risk. When the increased excitement resists the gentler means, as it is of the greatest consequence that it should be reduced at an early period, Ave must have recourse to venesection; and here the following remark of Sydenham is fully warranted by expe-» rience, " Vulgare illud atque tralatitium argumentum, quo ad- " versus phlebotomiam aliasque evacuationes utuntur, nempe, " quod non liceat a circumferentia ad centrum movere humores, " cum natura in hoc morbo contrarium adfectare videatur, nulla- " rum plane virium est." Where blood-letting is improper before the eruption, it must be s ill more so after it, when the fever either becomes milder or wholly disappears. Even in the distinct small-pox indeed,'the secondary fever sometimes supervenes. At its commencement it is a synocha, and we must again have recourse to blood-letting if the symptoms resist other means, remembering however that now the fever vrill not be relieved by the appearance of an erup- tion, but will suddenly assume the form of typhus if the .anti- phlogistic plan be pushed too faiv Some authors, and those of the highest authority, have recom- mended blood-letting at the very termination ofthe complaint, or rather after every symptom had disappeared. " Die decimo- «* quarto," Sydenham observes, li aegrum electo surgere pernu-1 " si, vicesimo priino sanguinem e brachio educendum curayi." " Superestut dicam," says Dr. Mead,* " nullam febrem magis «' requirere, ut morbi reliquix e corpore exterminentur, sanguis " igitur, si vires adhuc constent, convalescente jam asgro defra- " hendus est." _,,• This practice is uoav very generally abandoned, unless symp- toms demanding blood-letting supervene. -It Avas not however the mere offspring of hypothesis. The small-pox, like some of the other exanthemata, it Avas observed above, often leaves be- hind it a predisposition to inflammatory complaints; but U,is sufficient to have recourse to blood-letting Avhen the presence of these renders it necessary. The reader may consult Avhat was said in the first volume, of blood-letting during the apyrexia of intermittents, Avhich is altogethetapplirable to the case before us ; in which indeed there is an additional argument for not let- ting blood till the symptoms Ave dread sheAv themselves ; namely, that there is much less chance of their appearance, than of the recurrence of the paroxysm of an intermittent. Local blood-letting by scarification ofthe temples or leeches, is a valuable remedy Avhere the coma or inflammation of the eves-is considerable. * Monita et Prxcepta Medica cum ->otis Win':i-in^hair/,. SMALL-POX. 409 Although I had not arrived at the period of eruption when I had occasion to mention blood-letting, it appeared a more distinct plan to collect in one place the remarks to be made upon it, than repeatedly to mention it in speaking of the different stages of the disease. To return to the treatment of the eruptive fever. ' Of all the means employed for moderating the excitement du- ring this fever, none has proved so generally beneficial as the ap- plication of cold. Sydenham* Avas the first Arho in this country introduced the cool regimen in small-pox. It is one of his great- est improvements in medicine. The injury done by a high tem- perature, and the advantage of a free admission of cool air, in con- tinued fever, have been pointed out. Both are still more remark- able in the treatment of small-pox. There is perhaps no other disease in which cold is now applied so freely and with so much advantage. This practice has been long known in the East ; it is only in late times however that it has been introduced into Europe, for even the authority of Sydenham could not for a long time render the cool regimen in the small-pox prevalent. In this country it is noAv practised to a greater extent than he ventured to recom- mend. The patient is at no period of the disease confined to the house, whatever be the season, unless the fever be such as confines him to bed. When an exacerbation comes on he is taken to a cooler place, which generally relieves it. It is proper to keep his bed- room cool. For this purpose it will often be necessary to exclude the light as much as possible, ancl to promote a free circulation of air ; and, as Tissot recommends, frequently to sprinkle the walls and floor a\ hh Avater.f The patient should lie with few bed-clothes and on a mattress ; a feather bed always occasioning too great an accumulation of heat. A crouded room is particularly hurtful, the heat thus oc- casioned being the most pernicious of any. A free use of cold drink is equally grateful and salutary. It is almost unnecessary to observe, that our directions respect- ing the temperature must be regulated by the state of the wea- ther, and the severity of the symptoms. The free admission of the external air will be more necessary in Avarm than in cold weather ; Avhen the excitement runs high than when it is mode- rate. The temperature should always be such that the patient may experience no disagreeable degree of heat, but rather sen- * See his chapters De Variol. Regular. An. 1667, 1668,1669; and De Va- rioL Anomal. An. 1670, 1671, 1672. f See Avhat was said of diminishing the temperature of the patient's feed-room, in the treatment of continued fever. Vol. I. D d d 410 SMALL-POX. sation of cold ; except indeed he complains of being cold we need* not be afraid of currying the cool regimen too far. There is no part of this regimen more beneficial than frequent- ly changing the linen of the sick, Avhich should be dry but cool. The patient should be shifted at least tivice a day. There can be no doubt however, that the cool regimen, like every other mode of treatment, may be pushed too far. Dr. Makittrick Adair,* in a letter to Dr. Duncan, makes some ob- servations on the Suttonian plan of treatment ; that is, the very low diet and free exposure to cold ; ancl alleges that it often/ docs harm, especially when carried so far as entirely lo prevent the eruption. This hoAvever rarely happens, and although Dr. Adair's observations certainly demand attention, on comparing them with those of other Avriters, as Avell as with Avhat Ave every day see in practice, it will appear that he endeavours to restrict us too much in the employment of the cool regimen. Such are the means to be employcdin the eruptive fever of tlie distinct small-pox. And many have advised us to continue the exhibition of cathartics and the cool regimen in its full extent af- ter the eruption is finished, and even in cases where the fever lias almost or wholly disappeared. But if our view in the employ- ment of these means, is to moderate excitement, of what service can they be when the excitement has returned to the healthy de- gree ? The truth is that in such cases a perseverance in these measures is found to do harm. " After the eruption," Dr. Cul- len observes, " when a few pimples have appeared on the face, " the continuing the application of cold air, and the employment " of purgatives, have indeed been the practice of many inocu- " lators ; but I think these practices cannot be .Said to give any " particular adAantages to inoculation ; for when the state of the " eruption is determined, when the number cf pustules is very " small, and the fever has entirely ceased, I hold the safety of " the disease to be absolutely ascertained, and the farther use of w remedies superfluous. In such cases I judge the use of purga- " tives to be not only unnecessary, but that they may be often "hurtful." At the same time we must be careful to avoid the opposite and more dangerous extreme of relaxing too suddenly in the em- ployment of the cool regimen, which has often been attended with ^rm ing consequences.f The use of gentle laxatives, as far as is necessary to prevent costiveness, is to be continued ; and with regard to the application of cold, it should at this period be regulated by the patient's feelings. * See the 8th vol. of the Medical Commentaries. | A very striking instance of the injury done by an unguarded relaxa- tion ot the cold regimen is related by Mr. Perkins, in tlie 3d a'J. of \\ 2 Medical Observations and Inquiries. SMALL-POX. 4M IT on the other hand the febrile symptoms continue considera- ble, notwithstanding the appearance of the eruption the plan of treatment must not be relaxed. The continued use of cathartics and the cool regimen is then necessary ; and as at an early pe- riod they are the best means of moderating the eruptive fever, they are now the most effectual for preventing the appearance of the secondary ; which is always to be feared Avhere the remis- sion on the completion of the eruption is inconsiderable. The Indians, Dr. Rush informs us, plunge themselves in cold water as soon as they perceive the eruption of small-pox ; which is found to moderate the disease. Cold bathing in the small-ppx is also practised by Europeans in sultry climates. A person who had spent many years in the East-Indies informed me, that Avhen the pustules have a flaccid unfavourable appearance, on the use of the cold bath they become in the space of a few minutes Avell fill- ed and more prominent. If it be improper to persevere in tlie liberal use of cathartics when the appearance of the eruption has nearly or altogether removed the febrile symptoms, what shall we say of this practice after every symptom of the complaint has disappeared I " After having conducted patients through the " small-pox," Dr. Brocklesby*observes, " physicians have gen- *' erally supposed purgatives necessary, in order as they say to " carry off the dregs of this disease. I must own I have been " so far from placing confidence in the supposed advantage of " this practice, that I have been convinced that it tends too much " to weaken the body, already relaxed and broken by the prece- " ding disease." NotAvithstanding Avhat is here said, this practice is not wholly unfounded, but rests on the same foundation Avith that of blood- letting at the same period ; ancl, when curried to the extent that some have recommended, is nearly as objectionable. But as the small-pox leaves behind it a predisposition to inflammatory ^complaints, it is of great consequence for some time after this disease to guard against any accumulation of irritating matter in the bowels, which may be the means of inducing such complaints, as I have known it to be, and the patient thus nearly destroyed by an inflammation of the intestines. There is for the most part some foundation for modes of prac- tice which have been generally prevalent; and avc should be cau- tious in wholly abandoning them. It will ofien be found that their pernicious effects are owing to physicians having lost sight of the circumstances which first suggested them. Guarding against the accumulation of irritating matter in the primx a i^ iX this period must have always been found useful ; bui when phy- sicians beg.Mi to talk of draining off the dregs of the disease, and employedlhe same practice in all cases, wc emnot i^c biirpriaed that it Avas often hurtful. * Sec his work oa the Diseases ofthe Army. 412 SMALL-POX. When the fever continues after the eruption, we must expect a considerable exacerbation about the seventh or eighth day*. Means for moderating the febrile symptoms are therefore partic- ularly necessary at this period. Blisters have been thought useful, and some have advised a suc- cession of them for some days after this exacerbation; that is, after the commencement of the secondary fever. Blistering is certainly prejudicial when the synocha runs high, by increasing the excitement, which is admitted by Tissot, yvho is a strong ad- vocate for their exhibition after the typhus has appeared Blis- ters, like opium, he observes, recruit the strength, check the diarrhoea, and determine to the surface. It will be found however on comparing different writers, that the observations made on blistering when considering the treatment of synochus are appli- cable to all idiopathic fevers.* Except Avhen local affections are present little is to be expec- ted from them. I shall have occasion to speak of their use in considering the treatment of certain symptoms Avhich do not come under the general plan of cure. When blisters are used, the proper place for their application is to be chosen, without re- gard to its being covered with pustules. Although, Avhere coma is not considerable, the sleep is often much disturbed, opiates are a doubtful remedy, particularly in the eruptive fever, and at other periods, if the excitement is con- siderable. Some also dread their tendency to induce coma. Paracelsus was the first who gave opium to a considerable ex- tent in the smallpox ; and Sydenham, although he neglected the general plan of treatment adopted by Paracelsus and his fol- lowers, considered opium a valuable medicine in this disease. Some late Avriters defend this practice ; while others go so far to the opposite extreme as to condemn the use of opium in al- most every case of small-pox. The result of all that has been said on the subject appears to be, that if opium be given Avhen the excitement or coma is con- siderable, or if it be found to induce coma, it is hurtful; but in all other cases, especially where the watchfulness is obstinate, a quantity sufficient to allay restlessness, provided proper1 care be taken to prevent its constipating effects, is beneficial. Opium, upon the Avhole, is better adapted to the confluent than distinct forms of the disease. Burserius frequently em- ployed it to relieve the acute pains of the back and limbs which frequently attend the former. The reader will find some good observations on the use of opium in the small-pox, in Tissot's Letter to Haller on this disease. * See the observations of Dr. Browne Langrish on Blisters in his Trea- tise on the Small-Pox. 9M ALL-POX. 415 Although the eruptive fever in the distinct small-pox is al- ways a synocha ; yet towards the end of the disease, if the fe- ver has continued after the eruption, and especially if the secon-^ dary fever has supervened, a greater or less degree of typhus al- ways shews itself ; and then the mode of treatment is the same as in typhus from other causes. 2. Of the Treatment of Confluent Small-Pox. The more alarming the eruptive fever is, the more assiduoua must be our attention to every part of the cool regimen. On this head there is little to be added to what has already been said. It cannot be denied that an alarming train of symptoms have sometimes been induced by sudden and imprudent exposure to cold. The eruption recedes, the patient falls into syncope* or convulsions which sometimes terminate fatally ; and it is in the confluent forms of the disease that this accident is most to be dreaded ; ancl there, it appears from the observations of authors, chiefly at the time of maturation. It will be found however on reviewing the history of such cases, that previous to the expos- ure lo cold the patient had generally been debilitated by the hot regimen, or other improper modes of practice. When the dis- ease has been properly treated from the commencement, such a train of symptoms is a very rare occurrence. Instances of this kind ought not to deter us from the cautious application of cold even where the hot regimen has been employed at an early period. The immediate and sudden application of cool air has often snatched the patient from death.f Caution however is requisite. There is but one form of small-pox, in which the good effects of the cool regimen have been called in question, namely, the crystalline. Dr. Rogers of Cork, who had extensive opportuni- ties of treating this form of the disease, declares that he has not there found the cool regimen produce its usual good effects.^ In the confluent small-pox, where the fever is always consid- erable, every kind of irritation or exertion is injurious. The patient should neither attempt to Avalk about nor even sit up, as in the milder forms of the disease ; and all the directions respect- ing the management of the natural agents laid down in the treatment of synocha, are to be strictly followed. No part of the treatment of confluent small-pox demands more attention than the employment of cathartics. Whatever opinion * See the observations of Dr. Dimsdale and others. X See the observations of Sydenham, and Sir George Baker in his Treatise on this disease. X It is unnecessary to mike a separate division for the few observa- tions which apply exclusively to tlie anomalous small-pox. 414 SMALL-POX. we might form of them, where the excitement is above tire healthy degree; we should, a priori, in all cases where h L-M* below this degree, be inclined to dissuade from their exhibit! vn, except as far as it was necessary to prevent costiveness. A -U'ry extensive experience however has contradicted thisinferency,. Practitioners Avere first led to recommend catharsis in w^,,. ent small-pox from having observed that when a spontaneous ■!- arrhcea occurred, especially if it appeared early in the disease, ;!o pustules were less numerous, the fever more moderate, and i! «. SAvelling of the head less considerble. " A spontaneous db;- " rhcea," Dr. Cleghorn observes,* " often occurred with the be t " effects, particularly moderating the symptoms of the eruptive " fever ; from whence we learn," he adds, " how reasonable'it « is to give purgatives in this stage of the disease according to *' the rules laid down by Drs. Friend and Mead." " If an ap- " prehension," says Dr. Walker,f " of weakening the vital povv- " ers in this species of small-pox," viz. the putrid, " when nei- " ther diarrhoea nor any other apparent evacuation occurs, ex- " cepting what is discharged by the salivary glands, induce us " to suspend purging altogether or even delay it long, the prog- " nosis, in every case of this sort, must be desperate." In another place the same author observes, " Purging is much more " necessary in the confluent than in the distinct small-pox. But " farther," says Huxham,| " if nature neither by her own ef- " fort, nor the help of art, is capable of keeping the morbific " humor from falling on the more vital parts, but from an un- " fortunate translation of it is like to sink under its weight; as " upon a sudden retrocession of the humor of the face and hands, " a premature suppression ofthe saliva, and the like; cloth it " not seem necessary to carry off the offending matter by some " other out-let, as particularly by the guts, which are mucti u more easily and certainly solicited to discharge than the pores " of the skin, the urinary passages, or the salivary ducts." The reader will find cases to prove the benefit of purging in the con- fluent small-pox in Dr. Walker's Treatise just alluded to, andia a Treatise by Dr. Friend entitled " De Purgantibus in Secunda « Variolarum confluentium Febre adhibendis." « Videsuialiis,*' Dr. Friend remarking on these cases observes, '• inoptnatatf " prsesentissimamque opem attulerit purgatio $ ut aliis paulisper " subvenerit cunctatius per vices repetita."* - * Account of the Diseases of Minorca. f Treatise on Small Pox. X Treatise en Fevers, Small-Pox, &c. * Dr. Friend even relates one case, in which the gangrenous blistei* mentioned by Sydenham, and which he ahvays fouud a fatal symptom, appeared; which treated Avith mild cathartics,terminated favourably. 1 here are some good observations on purging in small-pox by Dr. Simson, Professor of Medicine at St AndreAv's. in ;he works cf Hoffman, Mead, and Wintringhaai, this practice is also \v a: arty recommended. SMALL-POXr 411 It is observed that the good effects of purging are not so soon ebserved where the excitement is considerable, and that in these instances their frequent repetition is most necessary. Upon the whole it appears, that cathartics are useful at all pe- riods of small-pox, and particularly during the eruptive fever, ancl at the time the secondary fever is expected, unless a diarr- hoea has supervened : and that they are the more indispensable the more severe the disease. They are necessary when the ty- phus shews itself, still more Avhen the excitement is considerable. Two circumstances in their exhibition always demand atten- tion : that the mildest cathartics are the best, ..drastic purgatives being only necessary where there is an unusual difficulty in mov- ing the bowels ; and that wherever there is much debility wc* must during their employment support the strength by cordials. If this caution be neglected, particularly in the worst forms of the disease, the danger may rather be increased than diminished by cathartics. It is the opinion of some that purging has been carried too far by many practitioners, particularly in the secondary fever. If we find the patient's strength sinking, notwithstanding the use of cordials and tonic medicines, it is necessary to discontinue the ca- thartics or to employ only gently cathartic clysters. To what the benefit derived from cathartics in the small-pox is to bo attributed, has not yet been determined. With regard to the hypothesis of the variolous matter being discharged in this way, to the confinement of which the danger of the small-pox has been attributed, it deserves little attention. Nor can it well be supposed that the advantages derived from purging, are to be al- together attributed to its expelling irritating matter which is apt to accumulate in the intestines in this disease. If future observa- tion should determine this to be the only use of cathartics in the sma!l-pox, ;t will considerably modify the treatment ; at?prescnt Ave have reason to believe that they are serviceable in some oth- er way. It has long been a practice in eastern countries, and it is re- commended by some late European writers, Tissot, Burserius, and others, to discharge the matter of the pustules by piercing them with fine needles, which occasions a copious secretion by the skin, for the pustules soon fill again, and are again opened, which is always done by making a very small aperture.* By this means it is thought the accession of the secondary fever is often prevented. There is certainly a striking analogy betAveen the prevention of the secondary fever in this Avay and by the use of cathartics, there being much similarity between the office of the skin and that of * It has been considered as dangerous to admit air into their cavities. 410 SMALL-POX. the intestines } but Iioav an increased secretion either by the one or the other, acts in preventing the secondary fever, is impossi- ble to say ; it is in vain to attribute their action to the evacuation of variolous matter, which has no existence till it is formed in the skin. In the confluent as in the distinct small-pox emetics are uue- ful at the commencement. They are also recommended about tlie seventh or eighth day if the strength is not much impaired, and seem often to moderate the symptoms of thesecondary fever. They are particularly indicated when the stomach is loaded. Less however is then to be expected from them, than at an earlier period ; and if any degree of typhus has shewn itself, they are generally hurtful. Such are the observations which apply to the treatment of con- fluent small-pox in general. What remains to be said may be di- vided into the treatment peculiar to the confluent small-pox, while attended by synocha ; and that peculiar to the worst forms ofthe disease, in which a confluent eruption is attended with typhus. On the former of these heads little remains to be said. While the fever is a synocha, the treatment of the confluent small-pox differs from that of the distinct in little more than degree. The means pointed out in the treatment of distinct small-pox are tote proportioned to the violence.of the excitement. It is to the confluent small-pox attended with synocha that nau- seating doses of emetics are best adapted, and here they often form the best cathartics we can employ. In the distinct small* pox they are too severe a remedy, und in the confluent attended with typhus are too debilitating. More harm may be done by incautious blood-letting in thecon«* fluent, than in the distinct, small-pox, and it is more difficult to determine when it should be employed. The confluent small- pox often sheAVS a tendency to visceral inflammations, and the fever itself at an early period is often characterised by great'ex- citement, accompanied with violent pains of the back, breast, arid bead; so that an inexperienced practitioner would judge very copious evacuation necessary. One acquainted with the disease however would recollect, that these symptoms are the forerunners of a confluent eruption, which is sooner or later attended Avith ty- phus, which Avill very suddenly supervene if debilitating measures are pushed far. The pernicious effects of such measures, which at first seem to promise much, are soon apparent. The pustules assume a more unfavourable character, black spots often appear on them, and the patient sinks under that train of symptoms which has been termed putrescent, enumerated in the preceding volume. The reader will find these observations illustrated in a striking manner, in SMALL-POX. 447 Dr. Cleghonv's Account of a Malignant Small-Pdx which raged in Minorca. With respect to the treatment peculiar to cases in Avhich ty- phus has supervened, almost all that Avas said of the treatment of typhus, properly so called, is applicable here. The typhus may either, as in the worst cases, sheAv itself in the eruptive, or what is more common, sooner or later in the secondary, fever. In the regular small-pox, typhus never precedes a distinct eruption, nor is such an eruption often follovred by any considerable degree of this fever. In anomalous cases, it often precedes, and more fre- quently follows a distinct eruption ; and to such cases the obser- vations about to be made are as applicable as to the confluent forms of the regular small-pox. It is only necessary indeed to make these observations, in order to shew that the treatment of idiopathic typhus is still the same. The earlier the typhus shews itself the greater is the danger, and the more assiduous therefore we ought to be in the exhibition of proper remedies. The diet, instead of being refrigerant ancl diluent, must here be stimulating and as nourishing as the state of the stomach admits of. Wine we still find the article on which 'experience teaches us to rely. It must be given alone or diluted according to tlie urgency of the symptoms, always in sufficient quantity to increase the strength and fullness of the pulse and to remove or diminish the delirium ; for such in all cases of idiopa- thic typhus are the effects of wine ; and except in extreme cases where the digestive powers are wholly suspended, these effects are increased by the addition of some farinaceous matter properly prepared* It was observed in detailing the symptoms of typhus that the delirium is sometimes, though rarely, of the furious kind. It ap- peared however, that notwithstanding the presence of this species of delirium, wine was the most successful remedy. 'k There-is " something very singular and deceitful in the common typhus,"' Dr. Walkerf observes, " in which the patient in the most violent *' delirium, tossing about his arms, speaking loud, and shewing " every instance of the greatest vigour, with a galloping hard u pulse, shall, be instantly composed and his pulse at the same ." time brought down, upon getting him to swallow a draught of " wine ; Avhen therefore small-pox is complicated with a disease " of this kind, it always produces a dangerous complaint, requir- " ing as much light support as the patient can receive, and wine " to be given frequently, not only when he is in a low and de- " pressed state, but when high and the delirium fierce." Dr. Walker relates a case which sheAvs in a striking manner the similarity of the effects of opium and wine in such fevers. They are not however to be used indiscriminately, as appears * See the Observations on diet in typhus in ike first rolurne, t See his Treatise on the Small-Pox. Vol. I. E c e f!8 SMALL-POX. from the observations made on their exhibition in typhus ; from- which and v. hat Avas said ofthe use of opium in the distinct small-- pox, the reader Avill readily perceive Avhen ancl how this medicine is to be employed in the various forms of the disease. " The advantage of conjoining with wine the Peruvian bark in confluent small-pox, is generally acknowledged.,,,Morton was among the earliest practitioners Avho employed the rbarlq in the confluent small-pox. Succeeding practitioners adopted the prac- tice, but the late Dr. Alexander Monro Avas the first who gave it freely in this complaint. It is now employed with the samefrecr dom as in common typhus. By the use of the bark, Dr. Monro observes, empty vesicles were filled with matter; Avatery sanies changed into white, thick pus; while'petechias became paler and at last disappeared. Whatever restores vigour, changes at the same time the state of the matter, from which in most cases the prognosis may with great certainty be collected. In many cases other astringents are employed with advantage. Alum mixed with Peruvian bark, Vogel* observes, is the best of all medicines when the pustules are bloody. Dr. Wallf also in- sists on the advantage of alum in such cases. The sulphuric acidf has also been celebrated in the confluent small-pox. Its acidity as well as astringency may be useful. Acids§ of all kinds have been much employed in this form of the disease. Dr. William Wright|| particularly recommends a mixture of vegetable acids and common salt in ail those diseases- called putrid. The various medicines which have been termed tonic and anti- spasmodic have been occasionally employed. On the use of these there is nothing to be added to Avhat was said of them when speak- ing of typhus, except what comes under that part of the treatment in small-pox Avhich still remains to be considered : the means to be employed when certain symptoms sheAv themselves, the treat- ment of Avhich does not come under the general plan of cure. These I shall consider the more at length, as the same obser- A'ations apply to the other exanthemata when similar symptomt appear in them. * Prelect Acad. &c. X Phil": ophical Transactions, No. 484, §. 4. X Dr. Brocklesby mentions an instance in which recovery seemed ow- ing to the exhibition of large doses of this acid. The patient took no less than an ounce ofthe acid, vit ten. daily. § I am induced by long and repeated experience, saysTissct, to regard mineral acids as the most valuable remedy Ave have in the small-pox. H See Dr. Wright's Letter to Dr. Morgan. SMALL-POX. 419 Inflammation of the brain is a more frequent accident in the ^crystalline than in other forms of small-pox. When the patient complains of an acute pain of the head, or is attacked with deli- .rium ; when the eyes are inflamed, and incapable of bearing the light, the carotid and temporal arteries beating strongly while the pulse at the wrist is small ancl feeble, Ave have reason to dread an inflammation of the brain ; and it unfortunately often hap- pens in such cases, that the patient is too Aveak to bear much general blood-letting. Local blood-letting therefore by scarifica- tion of the temples, or leeches, is what we chiefly trust to. If.general blood-letting be deemed admissible, the jugular should be opened in preference to any other vein, by which the general, serving at the same time the purpose of local, blood- letting, the symptoms will be relieved without pushing the evac- uation so far as would otherwise be necessary. Blisters applied to the head also make an essential part of the treatment. If the excitement be such as to Avarrant general blood-letting, the blister should be delayed till after the blood- letting. Few remedies, we shall find, are better calculated to relieve in- 'flammatory affections of the head, than.a discharge by the intes- tines, and no cause more apt to increase such affections, than any accumulation of irritating matter there. Gentle cathartics there- ■fore are doubly necessary, where any tendency to inflammation in the head appears. For a similar reason, fomentation of the lower extremities is useful. " In some cases," Dr. Walker observes, " Avhere the " delirium was obstinate, and there Avas reason to suspect too " great a determination of blood to the head, Avhich is commonly " the case,......I have found singular relief obtained, by a succes- •*' sion of flannel clothes dipped in hot water, very Avell Avrung " out, and applied to the legs, and continued for half an hour *l or more at a time." Other writers- make similar observa- tions. Inflammation is also apt to seize on other parts, particularly tha lungs, occasioning much difficulty of breathing and cough. Here the same means must be had recourse to, the local remedies be- ing applied to the chest instead of the head. But the treatment in such cases cannot be properly understood Avithout being ac- quainted with the phlegmasia, which will form the subject ofthe two succeeding volumes. Dyspnoea often supervenes in small-pox from other causes, a .pustulary affection of the larynx, trachea, and larger branches of the bronchke, or an unsuual degree of swelling in the Luces •which also impedes deglutition. In such cases, large blisters ap- plied as near the part affected as .possible are the most successful 42# SMALL-POX. remedy. The same may be said of difficulty of deglutition ia consequence of the viscidity of the saliva. Jn this case gargles, such as those recommended in the aphthse infantum, must at the same time be employed. Huxham* re- commends cyder and honey—or vinegar, water, and honey—or oxymel scilliticum with a little nitre or crude sal ammoniac. Bang recommends a gargle of oxymel of squils and water, and the application of sinapisms to the hands and feet, with gentle laxatives, and if the difficulty of breathing be great, the anthnoni- um tarisatum. Dr. Brocklesby observes, that small doses of ipe- cacuanha tend to restore the salivation when it is either suppres- sed or too viscid, and to alleviate the dyspnoea which often attends this accident. • When the state of the fever admits of full vomit- ing it is often the means of relieving the swelling of the fauces ancl promoting the secretion of salivat. The dyspnoea which sometimes folloAvs the sudden interruption of the salivation, seems frequently oAving to a degree of pneumonia supervening. In all these cases, when blisters and the other means which have been mentioned iV.il to bring relief, we must have recourse to local blood-letting, and in the last case general blood-letting is sometimes necessary. On the other hand, the salivation is sometimes so copious as to threaten suffocation from the fluid fulling constantly into the trachea, especially where there is any degree of coma. In this case Vogel thinks cathartics the most successful remedy. Profqse diarrhoea is a troublesome symptom in the confluent small-pox, particularly in children. Unless this symptom produ- ces a dangerous degree of debility, we must be cautious how we endeavour to check it; and even when it docs occasion much 3e- bility, the safest plan is to endeavour to moderate the discharge by tonic medicines. There is perhaps no instance, except to- wards the termination of the complaint, in which the diarrhoea can be safely stopped by opiates and astringents, and then it is to be done cautiously ; and when these medicines produce too sudden an effect, it must be counteracted by gentle laxatives > the diarrhoea is sometimes, thoiigh rarely, rendered profuse by exposure to cold ; some relaxation in the cold regimen is then proper. Obstinate vomiting is a dangerous symptom, both by reducing the stiength, and preventing the exhibition of medicines. If from the nature of what is evacuated, the vomiting appears to proceed from irritating matter collected in the stomach, we must * On Fevers, Small-Pox, &c. j Dr* Cameron dissuades from vomiting in this case, and alleges that it h-is sometimes occasioned suffocation. He strongly recommends breathing the steam of a decoction of marshmallows, myrrh, and honey in vinegar and vv ater. See the 22d vol. of the Gentleman's Magazine. SMALL-POX. - 4*1 Srvthe first place by draughts of some diluting liquor, enable the stomach to free itself of its contents. If they are bilious or acid, we must correct what may remain by acids or absorbents. If the vomiting proceeds rather from the state of the stomach itself than its contents, which may be known by the inoflensive- ness of the inaiter-rejccted, we must have recourse to such med- icines as tend to allay the tendency to contraction. Few are more powerful than saline draughts given in a state of effervescence. If these fail, a* few grains of camphire may succeed, or a dose of .solid'opium, or, what is perhaps the most powerful means we possets in obstinate vomiting, a combination of the two last medicines. The extract of cascarilla given in some .agreeable distiiled water is often serviceable in allaying vomiting.* The SAveating is sometimes so profuse as considerably to reduce the strength. In the wort forms of the disease however, and in i'lfants in any form of it, this symptom rarely appears, so that its excels is le.ss to be dreaded. When it shews a tendency to become profuse, tlie patient should avoid being in bed in the daytime, which, witii the cool.regimen ancl laxative plan, almost always sufficiently counteracts this tendency. . A suppression of urine sometimes comes on, particularly in the confluent and anomalous forms of the disease, and in some ca- ses proves obstinate. People in the vigour of life, and particu- larly those accustomed to a free use of spirituous liquors, arc most liable to this symptom. It seems generally to arise from neglecting evacuations at the commencement of the disease, or keeping the patient too warm. If, as frequently happens, it be attended with costiveness, Ave must begin with an emollient and laxative clyster. When the hot regimen has been employed, Sydenham advises the patient to be supported by two assistants, and exposed in his shirt to a cur- rent of cool air. The same practice is recommended by Bangt ancl others. Dr. Cameron of Worcester observes, in the22d vol. of the Gentleman's Magazine, " To facilitate the discharge of " urine which is often difficult in the smallpox, Sydenham directs " us to get the patients up and lead them about the room, but I w would beg ah young physicians to read Hoffman's Dissertation, " De Situ erecto, in Morbis periculosis valde noxio before, they " either advise or allow of this practice. 1 have known sudden ancl *'fatal effects from it in very hopeful cases. I think there is no " need to make so hazardous an experiment while salt of amber " is to be had, for that will seldom fail to answer this intention." The former part of this observation however is chiefly, if not wholly, applicable when the debility is considerable. Where there is much excitement, the casein which suppression of urine * See Vogel's Obs. on the treatment of Measles in his Prelect. Acad. J Praxis Med. Systematic* Expbsita. 4J2 SMALL-POX. most frequently happens, although it may be proper in the first place to try the salt of amber, there is little hazard in adopting Sydenham's plan ; and Avhere the increase of temperature is steady and there is no moisture on the skin, if this plan fails it may be proper to dash cold Avater on the legs, as is sometimes practised to solicit the alvine discharge. One or tAvo epileptic fits, it was observed above, even in the mildest forms of the disease, frequently precede the eruption without being attended by clanger. In the confluent and anoma- lous forms of the disease however, the fits are more frequent, and in proportion to their frequency more to be dreaded. This symptom is rare in adults, but in them it is most dangerous. When from the nature of the disease, Ave have reason to dread the frequent recurrence of epileptic fits, or when they have re- peatedly occurred in any form of the disease, avc must endeavour to moderate their violence and prevent their return. Blood-letting was at one time very generally employed for this purpose, but practitioners uoav agree that it is seldom successful; and the ope- ration of blisters, Dr. Cullen observes, conies too late. As the violence and frequent repetition of the fits generally de- pend on the violence of the primary disease, the various means of moderating this, are among the best for moderating and prevent- ing the fits. But of all the medicines Avhich have been employed* none have been found so frequently successful as opium, on which Dr. Cullen chiefly depends, and advises us to throw it in per anura while the fit lasts. Opium is not only useful as an antispasmodic, but also by pro^ moting perspiration, one of the best means, it has been found, to prevent the return of the fit. Dr. Walker recommends for this purpose a preparation similar to the compound powder of ipeca- cuanha. Vogel Avith the same vieAV recommends a mixture of cinnabar, the sulphur auratum antimonii, and musk. The last is also recommended by Dr. Brocklesby and Bang, Avho likewise employed some other of the medicines termed antispasmodic. There are none of these however much -to be relied on. Cata- plasms applied to the extremities are sometimes serviceable. Whatever other means are employed, gentle laxatives are not to be neglected, as the irritation of retained faeces might alone be capable of reneAving the fits, especially in children. The pustulary affection of the eyes is often very troublesome, and is sometimes followed by loss of sight- When the pustules are numerous on the face, the use of common mild and gently astringent collyria should never be neglected. M. De Lassone* recommends frequently wetting the eyes and eye-lids with rose- * See Memoire sur quelques Moyens de lemedier auxaccidens graves dans les Petiies Veroies, in the 3d vol. of the Histoiie de la Sorf£i6 Koyale de Mtiecine. 5MALL-POX. 437 water, in order to prevent the appearance of pustules; or, if they have appeared, to diminish inflammation. Burserius recommend* water, in which ignited iron has been quenched. It is of great consequence to prevent the eye-lids from growing together, which, as Vogel observes, is often the source of all the- mischief, increasing the pustulary affection and preventing the use of collyria. This accident may in general be easily prevent- ed, by bathing the eyes from time to time with Avarm milk. When the load of pustules on the face is very great, so that there is reason to think the eyes in danger, it has been recom- mended to immerse the extremities in Avarm Avater, and apply sinapisms to them, or even to scarify them.* Vogel condemns the common practice of moistening the face wiih a view to prevent or moderate the eruption there. When pustules have actually appeared on the eyes, we must have recourse to emollient poul- tices and mild mucilaginous decoctions ;t ancl fomentations are useful when there is much swelling of the eye-lids. It has been observed above, that in small-pox, as in other erup- tive fevers, a retrocession of the eruption sometimes happens, at- tended Avith an alarming train of symptoms. The means to be employed in such cases are in some measure influenced by the causes which produce the retrocession. The chief of these causes are, the sudden application of cold when the hot regimen has been employed, particularly if the cold be- applied about the time of maturation andwhen the patient is much debilitated ; fatigue, from remaining too long out of bed or in the erect posture ; syncope ; strong affections of the mind, particu- larly terror or grief; and above all, profuse evacuations. The remedies of most general application in such cases are wine and opium. These, Rosen observes, are particularly indi- cated when the retrocession is the consequence of profuse evac- uations. When it is the consequence of the sudden application of cold, increasing the'temperature and even the warm bath are generally of service, and the application of sinapisms and blis- ters in this case is particularly recommended. Musk and cam- phire, as in other cases of repelled eruption, are very generally employed. Vogel thinks the ammonia, the semicupium, and blisters applied to the feet, the most successful remedies. If, as sometimes happens, a diarrhoea supervenes on the retrocession of the eruption, it is generally of service and should not be checked. Some have recommended blood-letting on ihe sudden retrocession of the eruption. But if, as Burserius justly observes* whatever debilitates tends to occasion this accident, blood-letting * Vogel De Cog. et Cur. Morb. X See the observations of Burserius and Tissot 424 SMALL-POX. is surely the last means we should think of employing in such a case.* When the swelling of the face subsides, especially if it sub- side suddenly, and is not followed by the swelling of the hands,Dr. Brocklesby recommends the application of blisters to tho wrists and forearms, which often excites the swelling of the hands*; or if not, tends to obviate any consequences to be feared from its absence. When towards the period of maturation there is reason from the debilitated state ofthe system to apprehend' thae the swelling of the face may suddenly subside, Dr. Cameron, in a pa- per just alluded to, recommends the following plan, to which the author's extensive experience naturally calls our attention. « On " the day before the fate is expected to sink," he observes," I wrap " up the arms and legs lightly in a suppurating cerate ; the citrine, " for instance, spread on linen rollers and tacked together so as " to make one contiguous plaister."........"I assure you, I have M known adults in the confluent small-pox in less than an hour u after the application of these plaisters, cry out with joy that *' they were in heaven. I have seen the pustules as far as the " plaisters reached, ripen ancl fill even to bursting with laudable " pus, and this dargerous period pass without* one alarming "symptom." About the same period the Avhole body has been anointed with mercurial ointment apparently with good effects. Dr. Brocklesby also recommends blistering the wrists when the salivation suddenly ceases without any swelling of the hands. When the swelling of the face and neck is excessive, bathing the lower extremities and applying sinapisms to them, often re- lieves it. For the same purpose Tissot recommends the warm bath. When the eruption, Vogel observes, is delayed beyond the usual time, a single venesection, a dose of laudanum, or the tepfd bath, seem frequently to promote its appearance. Of these means, opiates only are admissible when the fever is typhus. Although, as was observed above, the eruption is generally earlier in the confluent, than in the distinct, small-pox, yet in seme ca- aes it is much later. When the pustules are longer of drying than usual, they should be opened ; ancl if the dried pustules adhere too long, fomenta- tions are the best means to make them separate. When the patient is plethoric we may let blood Avith a view to atop hemorrhagies ; in other cases v. e must trust chiefly to as- * The reader who has sufficient knowledge of medicine to separate facts from theory, will find some excellei.t obsei v ations on blood-letting in this case, in Dr. Cameron's Paper in the a>d vol of the Gentleman's Magazine. SMALL-POX. JibLiiaS re- gards as an irregular form of the disease. * * De Cog. et Cur. Morb. g 433 MEASLES. In the eruptive'fever of the irregular measles, there are not many circumstances to distinguish it from that of the regular. The symptoms in general are more violent and the fever is soon- er formed. The affection of the eyes, cough, and fever, being often considerable from the very commencement of the com- plaint. On the first night the patient is very restless, and on the next day tlie fever generally rises high, the cough and inflamma- tion of the eyes increasing. The eye-lids are sometimes so much SAvelled that they cannot be separated, and the eye-b 11 itself is often swelled and promi- nent ; and in some cases there is much pain and inflammation of the meatus auditorius. The pulse is now often more frequent, but less hard than in the regular measles. For the most part there is some degree of dyspnoea, and little or no expectoration attends the cough. When an expectoration of mucus attends the cough, Matthiew observes, it generally relieves both the febrile and local symptoms. The restlessness increases, with a parched skin, much thirst, and sense of tightness ancl oppression about the prsecordia. If coma does not supervene, the patient generally complains of an acute pain, often accompanied with a sense of heaviness in the head, or he becomes delirious. The fauces are of a deep red colour, and sometimes, Vogel •observes, assume the same appearance as in the cynanche maligna- Dr. Cameron, in the 21 st vol. of the Gentleman's Magazine, men- tions several cases in Avhich it had this appearance, so that he re- garded the complaint as a combination ofthe measles and cynanche maligna. The tongue is generally very foul, and the stools often unusually fetid.* The eruption frequently makes its appearance on the second or third day, it is sometimes delayed to the fourth, fifth, or even a later period. In the epidemic described by Dr. Watson, the eruption generally appeared on the second day ; whereas Burse- rius observes that in the irregular measles,, it frequently does not take place till the third, fourth, fifth, sixth, seventh, or even eighth, day. In one of Dr. Cameron's patients the eruption appeared on the sixth day. When the eruption, Burserius observes, is delayed to the fourth or fifth day, or longer, the excitement is less than in the regular measles. Debility often supervenes at an early period, the fever assuming the form of typhus. This change always indicates much danger, and if the patient escapes, his recovery is general- ly very slow. The eruption does not always appear first on the face, as in the * Matthiew. MEASLES. 439 more benign forms ofthe disease, but sometimes on the shoulders^ the neck, or breast. The duration of the eruption in irregular measles, is as various as that of the eruptive fever, though generally proportioned to it. When the eruption appears on the second day, it generally dis- appears on the fourth, or at most the fifth, or sixth day. When it does not appear till the fifth day. or later, it is often protracted to the tivclfth, fourteenth, or seventeenth, or even twentieth day, at different times assuming various appearances ; at one time red, at another pale or livid ; and in some cases it assumes a black ap- pearance. Whether the complaint runs rapidly or not, the febrile symp- toms generally suffer a considerable remission, and are sometimes for a short time wholly removed, after the disappearance of the eruption. In neither case however, is there any remission of tlie fever on its first coming out. But on the contrary the symp- toms just enumerated are generally increased at this period. If nausea ancl vomiting have not appeared earlier, they very fre- quently supervene after the appearance of the eruption, ancl rise to a greater height than in the regular measles. The affection of the throat increases; the same may be said of the delirium and coma, Avhen these symptoms have appeared at an early peri- od ; where they have not, either the one or the other generally makes its appearance noAv. The pulse becomes more frequent and less full, and when the disease has been protracted, small, fee- ble, and often irregular; the cough is rendered more violent, the hoarseness increases, the breathing corresponding to the state of the pulse becomes frequent and anxious, the dyspnoea some- times threatening suffocation. Symptoms denoting the last stage of debility succeed, namely, dropsical swellings, petechiae, hemor- rhagies, tremors, subsultus tendinum, and convulsions which are often the forerunners of death. In general, however, the fatal termination is delayed to a later period. In the irregular, as well as the regular measles, the symptoms which take place after the eruption has disappeared, are often most to be dreaded. Although the fever at this period generally abates, many of the symptoms become worse. The inflammation of the eyes sometimes degenerates into sores, which, if the patient survives, often continue to harrass him for a long time. The cough, dyspncea, and oppression frequently remain and are often increased, with a frequem, feeble, and sometimes irregular, pulse, ancl other symptoms of debility. In this state diarrhoea sometimes supervenes, and generally serves only to increase the debility. \YThen the delirium returns at this period, it is generally a fatal symptom. ^ "When on the contrary the skin becomes moist, the restless- ness is diminished, the cough and dyspnea r.batc, ancl the strength 440 MEASLES. begins to return, the pulse becoming fuller and less frequent, th© prognosis is good. Inflammation of the lungs is more frequent at all periods of the irregular than regular measles. Suppurations of the brain, internal ear, and other parts also, frequently occur in this form; of the disease, and sometimes prove fatal. Swellings noAv and then appear about the neck, on or about the fifth day, and arc a very unfavourable symptom. If the patient survives, they often form abscesses and give much trouble.* From Avhat has been said it appears, that the regular ancl ir- regular measles differ chiefly in the four following circumstances. I. All the symptoms, whether febrile or catarrhal, are general- ly more violent in the irregular, than in the regular, measles. 2. The fever in the former always shews a tendency to ty- phus. 3. In the regular measles, the affection ofthe fauces always re- sembles that produced by cold ; in the irregular, the fauces are frequently livid, and often assume completely the appearance of the cynanche maligna. , 4. The duration of the different stages of the irregular meas- les is more uncertain. The eruptive fever, as well as the erup- tion, in regular measles continue for a certain length of time, at least never much exceed, or fall short of, it. In the irregular measles, the course both of the one and the other is sometimes very rapid, at other times very lingering. The irregular measles might therefore be divided into two va- rieties, that in Avhich the symptoms run high and are soon termi- nated, and that in which they are less violent ancl longer protract- ed ; and there is the more room for such a division, as the one of these varieties has been epidemic without the other making its appearance. The same epidemic however often assumes both forms. Besides the regular ancl irregular forms of the disease, there are certain varieties as in small-pox, Avhich noAv and then occur in all epidemics. The fever with all its usual symptoms, Quarin obseri'es, has sometimes appeared without the eruption.. Others make ihe same observation, the accuracy of which is called in question by Frank, but not (it appears from a variety of observa- tions) on sufficient grounds. '• During this measly season," (it is remarked in tlie fifth vol. ofthe Medical Essays) « several peo- ple who never had had the measles, had all the preceding symp- " toms of measles, wnich went oM in a few clays without :my erup- " lion, which they underwent months or years after wards." The * Matdiiew. MEASLES. 441 reader will also find a case of the same kind related in Morton's work " De febribus Inflammatoriis Univers tlibus." The case is entitled, •' Febris morbillosa, absque ulla efflorescentia vel co- " mitan*e vel subsequente, sanata." ■ It even appears from the following observation, that the conta- gion of measles i iuy produce some of the symptoms peculiar to the measles, without either fever or eruption. Dr Home, in his account of the mmnei of communicating the measles by inocu- lation, which I shall presently have occasion to describe, observes, " March 27, inoculated a child of eight years old, with the same « blood av hich had been kept ten days loosely in my pocket-book ; " I was afraid when I used it that it was too weak. The sixth " clay this child sneezed much, but never was hot or struck out. " This child took the measles in the natural way about two months " afterwards." It also sometimes happens that, a few days after every symp- tom of the complaint is gone, the fever again returns, and is again attended with the eruption of measles. " But it often hap- « pens," an author in the 2d. vol. of the Medical Museum ob- serves, " after the measles are gone, the patient purged and re- « turned to his usual diet, that in the space of ten days he is sei- « zed with grievous oppression at the breast, and great anxiety, a " fever, thirst, some spots on the skin of a deeper red than the " former. Faint sweats and short breathing conclude the scene, " whereof many have died the last summer. And this fever " seems sometimes induced by cold, and overloading the stomach." The second appearance of the measles is most frequent in the irregular form of the disease. Matthiew observes of that of Alsace that soon after the eruption had disappeared, a new fever came on, followed by a second eruption. The following are the principal consequences to be dreaded from the measles, all of which are most apt to follow the irregular form of the disease. There is no complaint more apt than the measles to call into action, if I may use the expression, any scrophulous tendency. Hence the most frequent consequences of the measles are scro- phula in its various forms ; glandular tumors, marasmus from ob- struction in the mesenteric glands, obstinate sores* often affecting the bones, the most fatal of all forms of scrophula, phthysis puh monalis. Even where there is no tendency to phthysis, inflammatory af- fections of the lungs are frequent after the measles. * See the observations of Dr. Watson in the 4th vol. of the Medical Observations, and Dr. Huxham's Account of the Malignant Mcashs which raged at Plymouth in 1745. Vol.. I- H h h 443 measles; The bowels are often left in a very weak state, a chronic diarr- hoea remaining, which has sometimes proved fatal. If we except the lungs, no part suffers so frequently as the eyes, which (as appears from what has been said) are much affec- ted throughout the whole complaint. The ophthalmia often remains after the other symptoms, ancl becomes obstinate ; anil in some cases the sight has been lost from ulceration of the cornea, in others from an affection of the nerve, a true amaurosis supervening.* When the measles has been tedious and severe, it sometimes terminates in dropsy, which, like the marasmus, seems frequent- ly to depend on glandular obstruction. SECT. IL Appearances on Dissection. ON this part of the subject, there is little to be observed. If the patient dies under the eruption, the trachea and larger bran- ches of the bronchix, as in the small-pox, are often found cov- ered with it ; which may account for the increase of the cough after the appearance of the eruption. When the patient dies with a swelled belly and hectic fever, the glands of the mesentery are found indurated ; when of ph- thysis, indurated tumors of various size, some of them containing pus, are observed in the lungs. Such appearances however are not connected with the measles, but with other complaints, with which it is complicated. They will afterwards be considered more particularly. It was observed above, that inflammation of the viscera is more frequent in the irregular than in the regular measles ; in the for- mer also it is more liable to run to gangrene. Hence, in the ac- counts of the dissection of those Avho died of irregular measles, we find gangrene of some of the viscera an usual appearance. Dr. Watson observes of the putrid measles, " Of those who di- " ed, some sunk under laborious respiration, more from dysen- " teric purging, the disease having attacked the boAvels, and of " these one died of a mortification in the rectum. Besides this, " six others died sphacelated in some one, or more parts of the ? body. The girls who died, most commonly became mortified " in the pudendum." He also mentions ulcers, which some- times became sphacelated on the cheeks, gums, and jaws. " Several were opened," Dr. Watson continues, " under dif- " ferent circumstances attending this disease. In some who died * Vogel. MEASLES. Uc *c of laborious respiration, after the feverish heat and eruption Avere "*' passed, the bronchial system was found very little loaded Avith mu- *c cus, but the substance of the lungs Avas tender, and the blood vcs- " sels were very much obstructed and distended. In some Avho " died of laborious respiration and extreme debility, many strong " adhesions were found between the lungs and plevra. Tlie lungs " were distended with blood, and part of them had begun to " sphacelate. Part of the "jejunum was sometimes inflamed and " contained several worms." In some Avho died suddenly, it Avas found that the sphacelus of the lungs had occasioned a fatal he- morrhagy. " Collections of purulent matter," Dr. Watson adds, " were observed in none ; on the contrary, in this putrid disease, " every morbid appearance indicated a sphacelus." SECT. III. Of the Causes of Measles. THE measles, like the small-pox, seem to have been unknown to the ancients, although on this indeed there are some disputes.* The Arabians certainly first accurately described the disease. It is from them we have the name morbillk Rhazes, in particular, gives us both its symptoms and the mode of treatment practised in Arabia, which as well as the treatment of the small-pox was more judicious than it had been with us till early in the present century. From what we know of the history t>f measles, and what we eA'ery clay see, we cannot doubt that it arises from a specific con- tagion. So much Avas said of contagion in general, that there is little to be added here. The measles, like other contagious diseases, is not immediately produced when the cause is applied, but after the contagion has remained in the body for a certain length of time. The measles appear earlier after infection than the small- pox, and the time of their appearance is rather more uniform, being generally about the sixth and seldom later than the eighth day. Dr. Heberden observes however, that he has known the appearance of measles delayed even to the 14th or 15th day af- ter infection. The habits of body in which the measles are most apt to prove benign or otherwise, are far from.being well ascertained; almost all Ave know on this subject is, tha^ they are particularly unfavour- able in plethoric, and often still more so in scrophulous, habits. The measles appear to be less dangerous in pregnant women than the small-pox. Dr. Heberden says, he never knew any hurno * See die observations of Matthic ward others. 444 MEASLES. done by this complaint in pregnancy. It sometimes happens however, as in the case of small-pox, that the foetus in utero re- ceives the measles from the mother. The measles seldom attack the same person a second time, of which nevertheless there are a few well authenticated insiances. " Nunquc-m enim," Morton observes, " in tota mea praxi novi " quemquam, prater unum pueruin, secunda vice hoc morbo cor- " reptum." In the Medical Institutes of Burserius, the reader will find that the measles have not only appeared a second but even a third time in the same person. 4> Quod secundo et tertio " eundem hominem in eos incidisse ex ficlis observatis conslet;" and in the fifth volume ofthe Edinburgh Medical Essays, it is ob- served of the measles of 1735 and 1736, that many who had for- merly had the complaint Avere seized with all its symptoms, not excepting the eruption, which, it is said, resembled that caused by the stinging of nettles. The great success which attended inoculation for the small- pox, induced many to believe that similar advantage might be ex- pected from it in the measles. The very prevalent opinion of its being received in the natural way by the lungs, and the lungs be- ing the chief seat of danger in this disease seemed farther to strengthen the opinion. Dr. Home of Edinburgh, however, was the first who actually made the experiment. He met with some difficulty from the measles not forming matter, and his not being able to collect a sufficient quantity of broken cuticle at the time of desquamation, to produce the disease. " I then applied," he observes, " directly to the magazine of all " epidemic diseases, the blood." He chose the blood when the eruption began to decline in patients who had a considerable de- gree of fever. He also ordered it to be taken from the most su- perficial cutaneous veins where the eruption Avas thickest. While, the blood came slovyly from a slight incision it was re- ceived upon cotton, and an incision being made on each arm ef the person to be inoculated, the cotton, as soon as possible after it had received the blood, Avas applied over these incisions, and kept upon them, with a considerable degree of pressure. He also used the precaution of allowing the incisions of those to be ino- culated, to bleed for some time before the cotton was applied, that the fresh blood might not wash or too much dilute the morbillous matter. The cotton was permitted to remain on the part for three days. How far all these precautions are necessary to the success of the operation lias not been determined. D>\ Home inoculated ten or twelve patients in this wav, in Avhom the operation succeeded equal to his hopes. The eruptive fever .enenthy commenced six days after inoculation, and the symptoms of the complaint were milder than they generally are MEASLES. 445 in the casual measles. The fever was less severe, the cough ei- ther milder or wholly absent, the inflammation of the eyes was trifling; they watered however as much, ancl the sneezing was as frequent as in the casual measles; nor did bad consequences fol- low any case of inoculated measles. No affection of the breast remaining after it. The chief difference between the casual and inoculated measles seemed to be, the absence of any pulmonic affection at all periods of the latter. Dr. Home now regarded it as ascertained that the natural mea- sles are received by the lungs, and that on ttus circumstance de- pends the danger of the disease. He wished however to ascertain the symptoms of the complaint when evidently received by the lungs. He therefore put a piece of cotton which had remained in the nose of a patient under measles, into that of a healthy child, making him breathe through the infected < otton. The experi- ment although repeated did not succeed in inducing the disease. Nor, it is evident, if successful, would this experiment have de- cided the question whether or not the casual measles are received by the lungs. Dr. Home's experiments have not met with the attention they deserve. In scrophulous habits particularly, it would certainly be worth while to try his mode ot inoculation. If a more extensive experience prove it capable of producing the effects ascribed to it by Dr. Home, it will certainly be an improve- ment of considerable importance. The remains of the measles, to use the language of medical writers, seem to lurk in the body, that is, a morbid tendency re- mains for some time after this complaint, even where the patient appears to have regained his usual health. It Avas observed above, that when the small-pox supervenes on the measles, the former is often of an unfavourable kind. This lias been particularly remarked of the small-pox supervening on the putrid measles. SECT. IV. Ofthe Treatment of Measles. AS the treatment in small-pox is divided into that of the dis- tinct and that of the confluent form of the disease, so we may divide the treatment of measles into that of regular ancl that of ir- regular measles. It has often been observed that the treatment of small-pox and measles, like their symptoms, is similar. It will be found Iaoav- cver that almost all Avhich either in the symptoms or mode of treatment of these complaints is similar, is only what is common 446 MEASLES. to them and all other idiopathic fevers in which the synocha pre* vails. It is true indeed that catarrhal symptoms often attend the small- pox, but these are not essential to the complaint, and are at most so slight as to demand little attention. In the measles, they not only form an essential but the most alarming part of the com- plaint. As inoculation is not practised in the measles, we seldom have the advantage of certainly knowing under what complaint the pa- tient labours as soon as he is attacked. If however Ave find that he never has had this complaint, that about six days before the appearance of the fever he had been exposed to the contagion of measles, and that the fever is accompanied with the diagnostic symptoms pointed out, there can be little doubt of the nature of the disease. The information required hoAvever cannot always be procured, and the diagnostic symptoms are often not alone suf- ficiently decisive at an early period to mark the disease Avith cer- tainty, so that in many cases Ave cannot positively determine the disease to be measles, till the eruption appears. But this is not a matter of much consequence, since the train of symptoms present require very nearly the same mode of treatment, whether the complaint be measles, common synocha, or catarrh ; the chief dif- ference being that the same remedies are employed more assidu- ously in measles. The treatment of the eruptive fever of measles differs little from that of the eruptive fever of small-pox. The diet should be the same as in the more severe forms of the distinct 6malJ-pox,. We seldom see the measles so mild a disease as the most favour- able inoculated small-pox, for even in the least dangerous forms, inflammatory complaints are to be dreaded. On this account, Ave find practitioners insisting much on a diluent and antiphlogistic diet, one ofthe best means Ave possess of preventing tie appear- ance of inflammatory complaints. " Acarnibus quibuscunque " arcebam," Sydenham observes, ofthe diet in measles, " juscula " avenacea, hordeacea et similia, nonnumquam et pomum coctum " concedebam." " Dietam vero diluentem," Huxbam* remarks, " mollem, omni carni vacuam instituere oportet." Morton, Mead, Burserius, and many others, might be quoted to the same pur- pose ; the last of these even dissuades from the use of milk. M. De Lassone hoAvever, having experienced the good effects of milk in the small-pox, made trial of it in measles, and thinks it of great service, particularly when a bilious diarrhoea supervenes and be- comes profuse. Dr. Mead recommends asses' milk instead of that of coavs. But. in managing the antiphlogistic diet we must always recol- * De Aere et Morbus Epidemicis. MEASLES; 14T lect its tendency to produce debility, and in weak habits be care- ful not to push it too far. When the habit is very weak, Quarin justly observes, we must abstain from too much dilution. With 'regard to exercise, if the patient find himself inclined, from the commencement of the febrile symptoms, to remain in bed, he should not be prevented; at the same time there is no occasion to confine him to bed against his inclination. In alt cases, towards the period of the eruption, he feels fatigued and averse to motion. Whether the patient be in bed or not, extremes of heat and cold are equally to be avoided. By the former we always increase the febrile symptoms, hy the latter we run a risk of increasing the catarrhal. After the benefit derived from the application of cold in the small-pox was perceived, many recommended it with equal free- dom in the measles, and this practice is still defended by some, particularly the followers of Dr. Brown. Sydenham, who contri* buted more than any other practitioner of this country, to intro- duce the cool regimen, when he cautions against keeping the pa- tient too warm in measles, says nothing of the application of cold. "Nequeautem, vel stragulis vel igni, quibus sani adsueverant " quiclquum adjici patiebar." In other places he makes similar observations. Morton, the contemporary and almost the rival of Sydenham, adopted the same practice in this respect, and their ex- ample has been followed by the best practitioners since their time. This much at least is certain, that if experience has not proved the harm done by a free application of cold in the measles, the practice has not hitherto been sufficiently general to ascertain its safety ;* at present therefore we may say of the degree of tem- perature, as of the exercise in this complaint, that it should in a great measure be regulated by the patient's feelings. It is partic- ularly to be observed, that the partial or sudden application of cold, or exposing the patient to a current of air, is dangerous in the measles. In most cases it is necessary to have recourse to other means for diminishing excitement. It is needless to repeat what ha:. been said of nitre, saline draughts, 8cc. these are useful in all cas- es of excessive excitement. Acids, Quarin observes, are to be avoided, as they increase the cough. ' Gentle cathartics are indispensible in all cases. They are not only useful by removing irritating matter ancl diminishing excite- ment, but also by obviating the tendency to inflammation in the head. Neutral salts are here perhaps the best cathartics ; anal- ogy is much in favour of calomel. * See the 650th paragraph of Dr. Cullen's First Lines. 44* MEASLES. Emetics have not been much employed in this complaint, ex- cept for the removal of certain symptoms, the treatment of which does not come under the general plan of cure. The remedy which principally demands attention in measles, is blood-letting. Though the utility of blood-letting when the symptoms run high is generally admitted, there has been some difference of opinion respecting the period of the disease at which it should be employed. For the most part Sydenham did not recommend it till towards the end of the disease ; for which he has been criticised by many, particularly by Dr. Mead.* Had Sydenham however taken the trouble to defend his prac- tice in this instance, he might have found many solid arguments in support of it. Unless the inflammatory symptoms run unu- sually high, the danger at the commencement of the complaint is inconsiderable ; this period is succeeded by a greater or less remission, which is often followed by a more dangerous train of symptoms than any which preceded them. Why should we un- necessarily reduce the patient's strength in the two former sta- ges, when in the last, should the inflammatory symptoms run high, more strength than can remain after such a disease is re- quisite to bear without injury the only means Avhich can relieve them ? " As this fever,'' Dr. Cullen remarks, " is sometimes violent " before the eruption though a sufficiently mild disease be to fol- " low, so bleeding is seldom very necessary during the eruptive " fever, and may often be reserved for the periods of great- " er danger which are perhaps to ensue." The reader will find a paper, in the 4th vol. of the Medical Observations and Inquiries, by Dr. Dickson, in which Sydenham's practice with respect to blood letting in measles is defended, and Dr. Mead censured for his observations on it.f In some cases hoAvever, even unattended by visceral inflamma- tion, the excitement is sufficient to Avarrant blood-letting at an early period, and we are here to determine as in common syno- cha. When the excitement is such as threatens immediate dan- ger or much subsequent debility, we must have recourse lo ven- esection.J: * " Sanguis itaque, incipiente morbo. pro setatis ac virium ratione dc- " trahendus est." See Dr. Mead's Monita et Praicepta Med. In this observation we perceive the remains of the hypothesis which led to an indiscriminate use of blood-letting in fevers. | Dr. Dickson's defence of Sydenham rests on the latter not having met Avith cases in which the excitement was considerable in an early stage. But even when considerable, blood-letting should if possible be avoided at this period. X The presence of the menstrual discharge. Dr. Heberden justly re- marks, is no objection, as some have supposed, to the employment cf blood-letting in the measles. measles: 44» With regard to the employment of blood-letting at a late period fcf measles, it cannot be fully understood till the reader is made ac- quainted with its employment in inflammatory affections of the chest, which will afterwards be considered. It is remarkable that blood-letting sometimes removes certain •ymptoms remaining after measles, for the removal of which un- der other circumstances Aery little is to be expected from it. Thus it has removed cough, although unaccompanied by fever or the other symtrtoms denoting inflammation. It has even been found a successful remedy in the diarrhcea which remains after measles. " Quin et diarrhcea," Sydenham observes " quam mor- " billos excipere diximus, venscsectione pariter sanatur." Concerning the use of blisters, so generally recommended in this complaint, it is only necessary to repeat an observation al- ready made. If our view in using them be to remove fever, we ahall very constantly be disappointed ; if to relieve local inflam- mation, we shall find them a powerful remedy. I shall presently have occasion to make observations on the symptoms for Avhich they are employed. So long a course of antiphlogistic measures, as is sometimes requisite in the measles, often leaves the patient in a state of much debility ; it is therefore necessary as soon as the inflam- matory symptoms disappear, to use means for restoring the strength. In most cases a nourishing diet and a moderate use of wine will be sufficient, and the addition of the bark is proper if there is no reason to dread a return of the inflammatory symp- toms. Concerning the treatment of irregular measles, it will not be necessary to say a great deal. Like that of the confluent small- pox, it may be divided into the treatment of irregular measles when accompanied with synocha, and that necessary when the fever is typhus. In the former the treatment differs only in degree from that of the regular measles. Cooling laxatives and blood-letting are necessary, and must be employed in sufficient extent to reduce the symptoms of excitement, whatever be the period of the dis- ease. In measles, as in small-pox, a prejudice has prevailed against letting blood before the appearance of the eruption ; which demands as little attention in the one case as in the other. When the excitement threatens immediate danger or much sub- sequent debility, we must in the eruptive fever of measles, as in all other idiopathic fevers, have recourse to venesection. Nitre and kermes mineral are particularly recommended at this period by Matthiew. The chief difference in the treatment of irregular measles ac- companied with synocha, and the regular form of the disease, Vol. I. I i i 4S& MEASLES. arises from the fever in the former being* apt to assume the form of typhus. There is perhaps no febrile disease of this country more perplexing than a severe case of irregular measles, the ex- citement often indicating the most vigorous antiphlogistic means, while the succeeding debility frequently supervenes so suddenly as to render the use of these means even in the earliest stage pre- carious. What appears to be the best plan in such cases has more than once been pointed out. It consists chiefly, in avoiding blood-letting if the excitement can be diminished by safer means ; if not, em- ploying it only to that extent which the urgency of the symptoms absolutely requires. If the excitement is prevented from rising too high during the first days, the nature of the disease will soon sufficiently overcome it, ancl then every ounce of blood which has injudiciously been taken, adds to the danger. The tepid bath has been recommended Avhen the excitment runs high; like other debilitating means it is to be employed with caution.* When the fever has changed to typhus, at whatever period this happens, the opposite plan of treatment becomes necessary.— Evacuations and even refrigerants are then hurtful. Refrigerants, Quarin observes, are particularly hurtful when the patient is Aveak; and Hoffman relates the cases of three children under measles, who fell a sacrifice to the use of nitre. There are no observations, as in the case of small-pox, which establish the utility of purging after the typhus appears. Wine, bark, opiates, and as nourishing a diet as the stomach can receive, are then the remedies to be depended on. There is nothing to be observed in addition to what has already been said of the use of these remedies. Some have been afraid of the bark in every form of measles ; this fear however ap- pears to be wholly groundless. Among other writers on putrid measles, the reader ni£11 not spend time by laying before the reader the modes of division adopted by different Avriters, or by pointing out the ob- jections vv hi. h might be made to them. The objections consist chiefly, in many of the divisions not being marked with sufficient precision, so that it is often impossible to say what are the cor- i-esponc.ing divisions in the different accounts ofthe disease; as the reader will perceive if, for example, he compare together the different accounts of the plague in the Traite de la Peste, or any of these with the division adopted by Dr. Russell in his Treatise on the disease. In dividing a disease into varieties, each variety must Lc mark- ed by some symptom which constantly attends it. This symptom must not be accidental or unconnected with the state of tbe symp- toms in general, vvhich Avould rentier the division useless; but must mark a variety, in which the symptoms on the whole, and, what renders the division of more importance, the prognosis, dif- fer from those of other forms of the complaint. I shall not defer a particular account of the eruptions, namely, the buboes, carbuncles, &c. till after the different forms ofthe disease have been considered, as has usually been done ; by which we are forced to use terms before they have been defined ; r.cr on the other hard, is it proper, where'the virie'v is so grea', ta PLAGUE. 467 interrupt the account of the general course of the disease, in or- der to describe the different eruptions. It therefore appears ne- cessary to depart from the order Avhich has been pursued in laying down the symptoms of the other exanthemata, and to regard bu- bo, carbuncle, &c. as terms which must be defined, before pro- -ceeding to give the symptoms of the plague. SECT. I. Of Pestilential Eruptions. 1. OF Pestilential Buboes. A pestilential bubo-atits commencement is a small, hard, round tumour, readily perceptible to the touch, about the size and shape of a pea, it is moveable under the skin, the appearance of which is not altered at an early period, the bubo lying at a greater or less depth, and the swelling not appearing externally. As the tumified gland enlarges, it changes from a round to a 473 PLAGUE. blunt yellowish point, which, instead of adi-ancing to suppuration, became black to the size of a large field pea. The gangrene in this case however did not spread farther. The margin became of a dusky red, but appeared brighter as the suppuration Avhich threw off the eschar advanced. After the second day, this dif- fered from the third ancl fourth varieties only in the gangrenous part being of less extent and the pustule more raised. In other writers Ave find an account of carbuncles in some res- pects differing from the foregoing. Samoilowitz, in his Ac- count of the Plague of 1771 in Russia, observes, that the pete- chix or maculx are very large and confluent, and often turn to carbuncles a short time before death, which happens in the fol- lowing manner : two, three, or four large petechix run Together and form a large pustule ; sometimes a similar pustule arises on each petechix ; in either case, on opening the pustules a true car- buncle appears beneath. In the Traite de la Peste, it is observed of a plague which raged in the eastern parts of Europe, that pur- ple spots appeared on various parts of the body, in the middle of which arose small gangrenous tubercles. In the same publication Geoffry takes notice of a carbuncle, no part of which assumed a black appearance. Dr. Russell, how- ever, thinks that Geoffry describes its appearance at one period only. Dr. Gotwald describes a carbuncle, which on its first appear- ance was a small swelling, on the surface of which there soon arose a number of little vesicles in clusters, which in a short time were formed into an eschar. These carbuncles were generally situated in membranous and tendinous parts, about the knee, be- hind the ears, upon the toes, 8cc. A streak proceeding from car- buncles on the fingers has sometimes been observed and com- pared to a tail. Dr. Hodges mentions an eruption of vesicles, which in one ease he found covering the Avhole body. When the inflamma- tion was considerable, they sometimes became gangrenous, and Avere changed into carbuncles ; they then resembled Dr. Russell's third variety. There are certain eruptions Avhich now ancl then appear in the plague in some respects differing considerably from any one of the carbuncles just described ; in others resembling them. Such is the eruption which has been termed papulx ardentes, or fire bladders. Gotwald, (says Goodwin in his Historical Account) observed the papulx ardentes or fire bladders in tAvo patients only," both of whom recovered. They were as broad as a shilling, of an irregular shape, and the skin seemed as if it were shrivelled by fire ; at length they emitted a small quantity of moisture, and vanished in a few days. They appeared on the belly, thighs, and legs. PLAGUE, 473 But it would be tedious to enumerate all tbe various eruption* iff this kind which have been observed in different epidemics. The true pestilential carbuncle may be defined, a pustular or ve- sicular eruption, sooner or later running to gangrene. The eruption called anthrax, is nothing more than a carbuncle after it has become sphacelated. Carbuncles, to whatever variety they may belong, for the most part do not exceed the size of a walnut ; they have sometimes been observed considerably larger. The time of their appear- ance is uncertain ; they sometimes shew themselves on the first clay of the complaint, but more commonly not till a later period ; and when several appear on the same person, they generally succeed each other rapidly. They ha*e been known to come out as late as the eighteenth or twentieth day. Respecting the number which appears on the same patient, Dr. Russell observes, " Of those of the first and second species | tha^/ef Marseilles,|| and many others, the symptoms from the first were alarming, the complaint often appearing Avith violent and irregular shaking. Delirium is sometimes the first'symptom observed. At other times, a remarkable state of the pulse, which very suddenly be- comes so weak that it can hardly be felt, frequent, and intermit- ting, with much debility and languor, introduces the disease. The prostration of strength is sometimes so sudden and complete, that Mr. Smith, Dr. Guthrie$ informs us, saAv men in apparent * The bitter taste in the mouth the reader will find mentioned by differ- ent writers as characteristic of the plague- It is observed by some that a favourable change seldom happened Avhiie this symptom continued. f See Russell's Treatise on the Plague, and Orrxus on the Plague ot Moscow. X See Chenot de Peste. ]| See the Traile de la Peste. § See Dr. Guthrie's Observations on the Plague of Russia. PLAGUE. 473 £ood health, on being infected by the plague, suddenly drop down as if shot by a musket ball. Sometimes, instead of mere debility ancl lassitude, the patient is affected with extreme horror and de- spair, and his spirits so low that nothing can recall them. * At other times, the disease attacks with very slight chills, soon Followed by a burning-heat, which remains during the disease; as soon as the heat commences, the patient complains of insuffer- able head-ach ancl excessive thirst. Sometimes, as in the plague of Russia described by Orroeus, the patient is suddenly seized with violent shivering succeeded by a hot fit, the shivering and hot fit alternating several times. The first symptom of the plague is sometimes a violent beat- ing of the temporal arteries, while the pulse at the Avrist is small and feeble. In this case tlie heat is generally moderate, but the head-ach intolerable. In the plague which raged at Lyons in 1628, a burning heat in some of the- viscera, and a dull pain or rather great heaviness'of the head, announced its approach. The plague sometimes comes on with violent palpitation, and strong convulsive tremblings. .1 he plague which raged in Lon- don in 1665 often made its attack in this way. As the complaint advances, it assumes more of the appearance of the fevers we have been considering. The inflammatory symp- toms generally run high for the first day or two; but for the most part the plague assumes the form of typhus at an early period; and the patient soon becomes delirious or comatose. The delirium is sometimes of the furious kind, particularly, Orroeus observes^ in those of a robust and full habit, and in whom a full meal appeared to be the immediate exciting cause. In ge- neral however, the delirium is of that species which characterizes typhus, the patient appearing rather stupid than outrageous, and complaining of a pain at the heart, a symptom frequently observed in the plague. When coma comes on early, it has been looked upon as affording a worse prognosis than delirium, particularly if it suffers no evident remissions during the day time. Both de- lirium and coma indeed are almost always most considerable du- ring the night. The remission in the day time is generally more evident when the patient is delirious than when he is comatose. Whether he becomes comatose or not, there is always present a very remarkable muddy appearance of the eyes, which is some-r times observable at the very commencement, and is one of the most characteristic symptoms of the disease. This appearance of the eyes in some degree resembles that in the last stage of ma- lignant fevers. It is not however described as altogether such, for with the muddiness there is blended a degree of lustre. It is an appearance in short very remarkable to those who have seen it, but not easily conveyed in words. 480 PLAGUE. ChicoyneaU observes of this appearance of tbe eyes, « LeS « yeux etoient ternis, le regard fix6 et egar£ annoncoit la terreur « et le desespoir."* Chenot calls it, " Oculorum languor et mxstitia ;** in another place, " occuli tristes scintillantes," which last may almost be looked upon as a translation of Dr. Russell's account ofthe eyes. Tbe eyes, Orroeus observes, are unusually prominent and preter- naturally red, watery, and of a sparkling fierceness, but in the advanced stage of the disease, they sink, the redness goes off, and a little before death, they appear dull and as if covered Avith a film. This change may be observed to a greater or less degree, during each remission, for it is in the exacerbations that the pe- culiar appearance ofthe eyes is most remarkable. Almost all writers on the plague take notice of a peculiar cast of countenance, which to those who are conversant with the dis- ease, is one of its best diagnostics. It Avas the state of the eyes, Dr. Russell remarks, which contributed chiefly to occasion that confusion of countenance which he does not attempt to describe, but from which, after repeatedly observing it, he could with some certainty pronounce Avhether the disease was the plague or not. The danger is very generally proportioned to the degree of this symptom. When the eyes resume the natural appearance, parti- cularly Avhen this happens after sweats, the prognosis is fa- vourable. But in the form of the plague avc are considering, this hardly ever happens. In the comatose the muddiness of the eyes is most remarkable. Their fierceness is most striking in those who labour under delirium, particularly the furious deliri- um ; and it sometimes happens, that the coma and delirium, with the peculiar casts of countenance which accompany them, alter- nate with each other. In the delirious, however, there is still an appearance of muddiness, and the eyes retain some lustre in the comatose. These appearances of the eyes are leas remarkable in children than in adults. Such is the best account I have been able to collect from the observations of those who were conversant with the disease, of that peculiar appearance of the eyes Avhich all who have seen the plague agree, so remarkably characterizes it. The changes which take place in the eye are not always con- fined to its appearance only ; the retina is sometimes much af- fected. The patients complain of seeing sparks, flashes of fire, and various colours passing before the eyes; this is only a great- er degree of the symptoms termed muscx volitantes. Decep- tions of sight, however, are not frequent symptoms in the plague. Deceptions of hearing are still more rare. Deafness, as in other fevers, is generally a favourable symptom, but it seldom attends the plague. With respect to the other senses, nothing particu- lar is to be observed. The depravation of the taste, which is in * Trai'.i de la Peste. PLAGUE. 481 some measure characteristic of the plague, I have already had oc- casion to notice. The anxiety in many cases is extreme, the patient constantly changing his posture, and soon finding the present as uneasy as (lie last, so that he is sometimes perpetually in motion. When this symptom is considerable, it affords a very unfavourable prog- nosis. The appearance it assumes when at its height, which ge- nerally indicates the approach of death, is described by authors, who have termed it a mortal inquietude in very strong terms. The patient incessantly twists his body as if in agony, but is inca- pable of giving any account of his feelings, so that it is difficult to determine whether it is occasioned by a great degree of anxiety or severe pain. The temperature, in the progress of the disease, is various. While the chills continue to recur, its increase is not consider- able, and in the cases where it is most considerable, it seldom equals that which we often meet Avith in common synocha. The state of the pulse is also various. In most cases after the first days of the disease, in many after the first hours, and in some from the commencement, it is feeble and frequent. Some- times it is remarkably hard and small but regular, at other times it is irregular or intermitting, and at length fluttering. - During the exacerbations, it often becomes full, open, and strong, as Dr. Russell expresses it; after which it again sinks; but in a more advanced stage, a different change is observed du- ring the exacerbations, the pulse becoming so feeble that it can with difficulty be felt. It has been observed of the pulse in the plague, that though to a slight touch it is strong and full, it is often'easily compressed ; a state ofthe pulse not readily accounted for, Avhich is mentioned however by more than one author from their own observation.* The most striking fact relating to the state of the pulse in the plague is, that it has often been observed nearly natural while the other symptoms indicated much danger. As the disease advances the increase of debility is generally in- dicated by a considerable affection of the speech; in some cases amounting only to a degree of confusion and faltering, or a change of tone ; in others the voice is greatly impaired or wholly lost. The affection of the voice appears the earlier, the greater the debility. When this is excessive from the beginning, when, as Chenot observes, " jEgri ereeti stare aut sedere impotes, proprio * In the Trai e de la Peste the reader will find this state of the pulse mentioned both by Chicoyneau and Conzier. " II ecoit ouvert ct aninc." Tne former observes, " II disparoisoit cependant si on prossoit l'ariere *' avec le doigt." Vol. I. Nnn 482 PLAGUE. " pondere labebantur," a considerable affection of. the speech is generally observed on the first night, or the second at farthest. Vv hen tie debility is less considerable, it is delayed to the third day or later. The state of the tongue, as in other fevers, is various. It often retains the natural appearance throughout the greater part of the disease. Sometimes it is moist, and covered with thick mucus at other times dry. " Sometimes," Dr. Russell observes, " it bc- " came parched with a yellow streak on each side, and reddish 11 in the middle, but it never Avas observed to form so thick a fur " or become of so dark a colour as in the advanced stages of some " other fevers. The dryness or moistness of the tongue," he adds, u rarely corresponded with the febrile symptoms, for the " tongue was often moist where the external heat Avas intense " and the pulse indicated high fever ; and on the contrary, parched " where the fever in appearance was very inconsiderable." Vomiting, though more frequently observed in less violent forms of the plague, sometimes attends this variety. The pain at the heart, so frequently complained of, Dr. Russell thinks situ- ates ibout the orifice of the stomach. As it often accompanies vomiting, be was at first led to believe that it arose from bile or oiher irritating matter in the stomach. He found hoivever that it w as not relieved by the discharge. It seems more thap proba- ble, from the nature of the symptoms, that this pain proceeds from an inflammatory affection of the stomach. The matter evacuated by vomiting is generally bilious. It is sometimes of a dark co- lour ancl mixed with blood ; and it is not uncommon in the plague for worms to be thrown out by vomiting. Whatever be the ap- pear uce ofthe matter rejected, when vomiting occurs at an early period and returns at intervals, the prognosis is bad. Nausea Avithout vomiting is a frequent symptom. It does not seem to proceed from irritating matter in the stomach, as repeat- ed vomiting is not found to relieve it. There are few means more efiecturi ior allaying nausea and vomiting than those Avhich pro- mote the perspiration, it has been observed of the plague, (that if tie repeated reaching occasions a moisture on the skin, the nausea abates. A diarrhoea is apt to supervene, sometimes during the first days, more frequently at a later period. This is invariably a dan- gerous symptom. Ihe matter passed by stool is similar to that rejected by vomiting, often bilious, frequently with an evident admixture of blood ; sometimes blood only is passed. Chenot of- ten met with dysenteric purging in the plague. As there are few fevers in which purging is so unfavourable, so there are none in which constipation appears to be less injurious. PLAGUE, 48S ■'* A number of the sick," Dr. Russell observes, " were disposed " to be costive throughout the disease, ancl some had no stool for " several days, the popular dread of provoking a diarrhoea proving " a bar to laxatives and even to simple clysters, which are readily " admitted at other times. The consequences of this sluggish- rt ness ofthe bowels were by no means Avhat might have been ex- " pected, for on comparing a number of cases in which the body " had been all along regular, with others in which there had been " no stool, the former did not appear to have been particularly " exempt from those symptoms which might plausibly have been " imputed to costiveness in others." The urine is often observed in no respect different from that of a person in health ; at other times it is found pale, high coloured, clear, turbid, without sediment, or with a great deal, and sometimes more or less tinged with blood ; in short, it assumes in different patients, or sometimes in the same at different times, ail the va- rious appearances observed in other fevers. There is no excretion of such consequence in the plague as that by the skin. When the skin remains parched, or av hen only slight, clammy, partial sweats appear, the prognosis is bad; when on the other hand a thin, general, and copious SAveat takes place, it often,proves more or less critical. Dr. Russell observes, that the breath and perspiration were sel- dom or never fetid. Other writers however have observed that they are often fetid to a great degree. As in,many, perhaps in all the other exanthemata, epileptic fits now and then occur. They are a rare symptom in the plague. When they appear, they generally precede an eruption. Slight convulsive motions of the limbs and subsultus tendinum are frequent; with respect to other convulsive motions, hiccup, rarely, and sneezing almost never, attends the plague. Hemorrhagies are a common symptom, and unless very mod- erate, generally indicate much danger. They are frequent, as appears from what has been said, from the stomach, intestines, and kidneys. They are more common however from the nose, and in women from the uterus, than from other parts. These, particularly the hemorrhagy from the nose, when they occur ear- ly in the disease, and the patient is young and plethoric, some- times bring relief. At a later period, hemorrhagies are always unfavourable, and when they become profuse, the patient seldom recovers. It has been remarked, as might have been inferred a priori, that the blood which flows in these hemorrhagies is thinner in proportion as the disease is further advanced. Such are the symptoms of the Avorst form of the plague. The strength gradually sinks, till the pulse impresses the finger Aviih cnly a weak undulating, or tremulous motion, with frequent in- 484 PLAGUE. termissions. The surface, particularly on the extremities* be- comes cold and covered with clammy moisture, the pulse cannot be felt, and the patient calmly expires, or, as frequently happens in all idiopathic fevers, is carried oft' by convulsions. The second and more common form ofthe plague, that accom- panied with buboes, includes endless varieties. W hat I am about to say of this form, may be divided into two parts ; the circum- stances in which it differs from the preceding form, and those in which its principal varieties differ from each other. In the first place, of the circumstances in Avhich this form differs from the preceding. In the second form of the plague, according to the division I have adopted, buboes always make their appearance on the first, second, or third clay, or later. If Ave excepl the appearance of buboes, Ave shall find no symptom constantly attending the one, and never present in the other, form. There are certain symp- toms however more frequent in the one than the other. Both vomiting and diarrhoea are most frequent in cases where buboes are about to appear. They sometimes attend from the commencemeni ; at other times supervene at a later period. Wnen the vomiting and purging commence early, they often continue to harrass the patient through a great part ofthe com- plaint. Although the delirium and coma are sometimes as uniform in this, as in the preceding form of the disease, it is not. generally the case. In most instanct s indeed, some degree of these affec- tions comes on in the evening, ancl continues through the night, bin in the majority of cases, unless the disease is far advanced, the patient during the day is nearly and sometimes altogether fr.c- from them The sudden depression cf strength also is upon the whole less remarkable, and the pulse for the most part contin- ues longer full, and is less apt to become irregular. The curation of the complaint upon the whole is longer, pe- techix and vibices are more common, and tlie body more fre- quently becomes livid and black after death. In short, the differ- ence between the general course of the symptoms in the first and second forms of the plague, is, that in the latter they are upon the whole less alarming and more protracted, the patient often labour- ing under various symptoms for some-days before the fever is formed* In the danger and rapidity of the second form how- ever there is great variety ; it varies from a degree of severity nearly equal to that of the first form, to a degree of benignity ap- proaching to that of the last, in Avhich the eruptions are unaccom- panied by lever. * See Avhat Orrceus calls the period of infection, in his Account cf the Plague of Russia, PLAGUE. 485 Although the varieties of the second form are in reality end- less, there are only three which can be distinctly marked, for (notwithstanding the numerous divisions of authors) I can discov- er no symptom which characterizes different gradations included under any one of these varieties ; and varieties ill characterized, instead of rendering the subject clearer, increase its perplexity, by holding forth distinctions which the reader soon perceives, nature has not made. Surely vomiting occurring more or less frequently, or coma supervening at an earlier or later period, af- ford no sufficient njarks for characterizing different varieties of the plague, unless it can be shown that the general course of the disease is materially influenced by the absence or delayed appear- ance of such symp-.oiiis, which on perusing the account of differ- ent epidemics we do not find to be the case. The first variety of the second form, according to the divis- ion I have adopted, is characterized by the buboes not appearing till the second or third day. In this case the symptoms are generally more violent, and the prognosis Avorse, than when they appear on the first day of the complaint, which characterizes the second variety of this form ; in the third, the eruption of buboes is among the first symptoms in which case the febrile symptoms are for the most part still milder. Many cases of the first of these varieties so much resemble some of the first form, that the difference consists almost solely in the appearance of buboes in the former ; thus the first and se- cond forms of the plague imperceptibly run into each other ; but the symptoms of the first variety of the second form are in gene- ral less severe. The pulse generally continues pretty full and tolerably strong till the second day, during which, for the most part, it becomes weak, and sometimes intermitting. The peculiar dejection of countenance, with the muddiness of the eyes, which come on more early in the very worst cases, frequently supervene at this time. Irregular flushing, a sense of internal heat, pain about the prxcordia, and incessant inquietude, at this period afford a ve- ry fatal prognosis ; as in the first form, these symptoms often pre- cede that diminution of temperature and cold dampness of the surface, which announce the patient's death to be inevitable, which is often hoAvever, after the appearance of these symptoms, at the distance of a clay or two. After this however, although the heat of the body returns, the symptoms upon the whole gra- dually become worse. When the strength has not been greatly reduced by the vomiting and purging, a remission is often obser- ved on the third day, but if the foregoing train of symptoms has previously occurred this remission is always fallacious, the dis- ease returns with redoubled violence, while the powers of resis- 486 PLAGUE. ting it are enfeebled. The patient often survives to the fifth or sixth day or Isfter, the remissions constantly becoming slighter, and the exacerbations more severe. On the second or third day, sometimes later, buboes make their appearance, in general without bringing relief ; carbuncles also frequently supervene with no better effect. This however is not uniformly the case ; Chenot observes, that the eruption of buboes and carbuncles was often attended with an evident remission of the symptoms. In some epidemics, Waldshmidt* remarks, when the symptoms were most alarming, the appearance of bu- bpes often saved the patient, but in others they were not followed by any remission. In this variety the body is frequently covered with petechiae or vibices, and the corpse often becomes black. The malignant train of symptoms just mentioned as appearing on the second day, sometimes do not supervene till a later period. At whatever time they occur, however, they almost always afford a fatal prognosis. In some favourable instances, especially where the vomiting ancl purging do not occur or at least not in such a degree as greatly to reduce the strength, the foregoing train of symptoms does not appear at all. and the patient escapes. In such cases the delirium or coma seldom comes on before the second night, and the remissions vvhicfi take place in the morn- ing are more considerable. These flattering appearances how- ever often prove deceitful, and even a salutary sweat on the morn- ing of the third day i6 sometimes succeeded by a fatal train of symptoms. These sometimes do not appear till the fourth day, and the pa- tient after their appearance frequently experiences a remission in the mornings ; the exerbations however gradually become more severe, and death is only delayed. In this variety, death for the most part happens on the fifth day, sometimes not till the sixth, seventh, or eighth, and then the symptoms are generally milder, and the buboes appear early on the second day. Few recover from this variety. In the second variety of the second form of the plague, ac- cording to the division 1 have adopted, buboes appear on the first day. Here the symptoms are wonderfully varied Many cases are equally fatal with those which have been considered, but this variety upon the whole is less so. Dr. Russell observes of his fourth class, Avhich corresponds to this variety, " The fourth class was the most numerous of all, " comprehending those forms of the disease, which from the " various and sudden changes in their course so often though not * See Haller's Disput. ad Hist, et Cur. Morb. Pert. vol. v. PLAGUE. 487 * constantly met with, cannot easily be represented in concise " ancl connected description ; I therefore enter on the attempt " with diffidence, and as a supplement for defects, must refer to •' the cases themselves noted below. The distinctive marks of " this class are, the continuance of the inflammatory and febrile tt symptoms with less interruption than in the former ; a pulse ** more constantly sustained or soon recovering itself when sunk u and hurried in the excerbations ; the length and rigour of the " excerbations decreasing in the advance of the disease ; and a- u bove all, the prevalent tendency to a favourable crisis by the " skin, with the critical sweats on the third, fifth, or subsequent « days." Vomiting is not so frequent a symptom in this variety as in the former, but upon theAvhole the first symptoms of these varieties arc not very different. Some hours after the commencement, a bubo begins to shew itself, and now and then more than one.— Notwithstanding this, the symptoms are sometimes as severe as' in the foregoing variety ; for the most part however they arc milder. The fever is more moderate ; delirium or coma still more rarely appear on the first night, during which the patient is less restless and anxious. But from he state of the symptoms at the com- mencement, we cannot judge with certainty respecting the event, those often escaping in whom the first symptoms are severe ;— whilst others, in whom the febrile symptoms are milder at an ear- ly period, are carried off' after lingering for many days. The remission on the second morning is generally considerable in this variety, and during the second day the symptoms often undergo n.any different changes ; at one time the febrile symp- toms running high, now ancl then even accompanied with a degree of coma, soon afterwards a very evident remission taking place, which in many cases is only a prelude to a new exacerbation. These exacerbations are often followed by a sweat more or less general, and which is found in proportion as it is general to bring relief. The most general sweats commonly occur in the morning, and consequently the most evident remissions. At oth- er times the sweats for the most part are partial, and the patient during the remissions, anxious and oppressed. The morning sweat of the third day often proves completely critical, or bring* such relief that the patient remains free from danger. These may be regarded as the most favourable cases of this variety ; they seem to be the same which M. Chicoyncau des- cribes in the following manner. If all those of the former class die, he observes, others might indulge more hope. The latter were seized at first with the same symptoms as the former, but they disappeared on tne second or third day. Nature and art, he remarks, seemed equally to conduce to this happy effect; the for- 488 PLAGUE. mer collected the poison which had been every where diffused through the system into the buboes and carbuncles, which sup- purating, spreading, and throwing out the matter they contained, formed a kind outlet through which the pestilential virus flowed,* while art aided this evacuation, which always proved salutary when it was not neglected-t But many cases of this variety are less favourable. The remis- sion on the third day is but imperfect, and the exacerbation soon returns. If during this there be an evident change in the state of the pulse, if from having been pretty full and strong it become weak and fluttering, the prognosis is bad. After this, the pulse varies in frequency, but seldom recovers its strength. When the change in the pulse is less remarkable, however, the sweat which returns on the morning of the fourth duy often brings more relief, and if the exacerbation on this day be less considerable, the sweating is more profuse and brings more re- lief on the fifth- and a third profuse sweat on the morning of the seventh day often completes or nearly completes the recovery. It has been remarked, that the sweats in this class of patients are more profuse and bring more relief on the morning of the odd, than on those of the even days. All the patients who escape however do not recover in this way, but often very slowly, and without any sweat or with very little, the complaint gradually abates. In the last variety of the second form of the plague, namely, where the eruption of buboes is among the first symptoms, ma- ny cases are attended with a considerable degree of fever, some- times protracted for six or eight days ; but comparatively few are attended with much danger. Chenot gives the following short account of his first division of the plague, which nearly corresponds with this variety. '■ Su- " binde vix ulla bubonis ortum prxcedit stipatve xgritudo. Ipse li carbunculus nonnunquam prodit prxvia tantum miti commo- •■' tione febrili, manifestior tamen plerumque est quam in bubone." In this variety the patient is sometimes not even confined 10 the house, and very often not to bed. In short, the mildest cases of this variety almost resemble the last form of the plague, namely, that in which the eruptions are the only symptoms. Such are the symptoms of the plague, and such the gradations by which the firsi form runs imperceptibly into the last, a disease. as different from it as can be imagined. * It is almost unnecessary to warn the reader of the groundless nature *f this hypothesis. X See the observations of M» Chicoyneau, in the Traitc de la Peste. PLAGUE. 489 Before leaA ing this part of the subject it is necessary to observe, that although most cases of the plague will be found referable to some ofthe foregoing heads, yet there are many anomalous cases which cannot be arranged under any one description, as they dif- fer from each other, as Avell as from all other cases. The only way of describing these is to give the cases themselves; this the reader will perceive Avould be endless. Dr. Russell forms a separate class for such anomalous cases, without however attempting any general account of them ; all he observes is, " This class being reserved for such cases as were " dubious, anomalous, or extraordinary, varying more or less in " some material circumstances from any of the foregoing classes, " admits of course of no general description. The particular " cases, to which have sometimes been subjoined occasional re- " marks, may be consulted agreeably to the references made be- " low to the journals." An account of such cases would not only be tedious but of little use, since the anomalous cases of one epidemic are not always found to resemble those of another. All that can be done, is to warn the practitioner that anomalous appearances are to be looked for, which do not hoAvever seem materially to influence the mode of treatment. SECT. III. Of the Causes of the Plague. THE history of the plague is involved in much obscurity, so that it is impossible to say from what source, or where, it origi- nated. The earliest plagues of which we have any account raged in Egypt and other parts of Africa.* We are sufficiently acquainted with its history however to be assured, that like the Other exanthemata it arises from a peculiar contagion* Professor Stoll of Vienna indeed, and some others, have combated this opinion, but it would be mispending time to trouble the reader either Avith the arguments of these Avriters, or any refutation of them, as they have scarcely noAV a single advo- cate.! It will be unnecessary here to make many observations on con- tagion, as this subject has already been considered at length. It is needless to repeat what has been said of the means of prevent- ing the generation and checking the progress of contagious disr * See Waldshmidt's Treatise on the Plague, in the fifth volume of Hal- ler's Disput. ad Morb. Hist, et Curat Pert. \ See the Traite de la Peste, and Dr. Russell's Avork on the Plague, Vol. I. O o o 490 PLAGUE. eases ;* and it would be tedious here to describe lazarettos and the various precautions employed to prevent the introduction of the plague from foreign countries ; for these I shall refer tlie reader to the works of Mr. Howard and Dr. Russell. Some facts would lead us to suppose that peculiar states of the air are favourable to the production of the plague ; it has some- times appeared in many parts of a country at the same timet More generally however it appears at first in one place, and spreads gradually to others. Like other contagious fevers, warm weather is generally fav- ourable, and cold Aveather unfavourable, to its progress. The plague was greatly Aveakened, De Mertens informs us, while the thermometer stood between sixteen and twenty degrees below frost. It often happens however, that its violence is not checked by the winter, and there are many instances of the plague ceasing in the warmest seasons of the year. In all the plagues Avith which Aleppo has been visited during this century, the Rev. Mr. Dawes observes, it is said to have regularly and constantly ceased in August or September, the hottest months of the year. Like other contagions, that of the plague is active only for a very short distance around the patient. The physicians, De Mertens observes, often went within a foot of the patients, with- out being infected. The young and robust, the same author observes, were more liable to infection than the old and infirm. It has often been re- marked of the plague, as of most other contagious fevers, that infants are less liable to it than adults. Waldhsmidt saw several infants who sucked nurses ill of the plague,, and yet escaped in- fection. He even observes, that one infant sucked two nurses ill of the plague, both of Avhom died, yet the child did not receive the disease. A Avoman who suckled her child five months old, was seized with the plague and died after a week's illness, but the child Avho sucked her and lay in the same bed Avith her, escaped the distemper.^ De Mertens and others make the same obser- vation. It is remarkable, however, that the foetus in utero sometimes re- ceives the disease, and that even where the mother escapes. * De Mertens recommends, as a good preventive, wearing a cloak of oiled cloth over the cloathes, while in the rooms ot the sick. It has also been recommended to anoint the body with oil. De Mertens thinks is- sues not to be depended on. The reader will find, in his Treatise on the Plague of Moscow, formulx for what have been termed antipestilential powders; they are similar to the fumigating powders mentioned in the first volume when speaking of the purification of fomites; the manner of using them also, is there pointed out. t See a Letter by the Rev. Mr. Dawes from Aleppo, in tlie third vo- lume of the Medical Museum. X Mr. Dawes's letter. PLAGUE. 4*1 *« Lost year as well as this, says Mr. Dawes, there has been more " than one instance of a woman's being delivered of an infected " child Avith the plague sores on its body, though the mother her- " self has been entirely free from the distemper."* It was observed of some of the other exanthemata, that cer- tain constitutions are incapable of undergoing them; the same seemsto be true of the plague. Waldshmidt knew a Avoman who was servant in a family Avhere seven people died of the plague, and afterwards in another all of Avhom died of it, ancl yet remained uninfected. A Greek lad, Mr. DaAves observes, made it his business for many months to wait on the sick, and to Avash, dress, and bury the dead, yet escaped the disease. Those who have once had the plague are less subject to it than others. This circumstance, together Avith the success which had attended inoculation for\he small-pox, induced some to recom- mend inoculating for the plague, which has actually been done. In Dr. Guthrie's Letter to Dr. Duncan there is an account of a surgeon, Mathias Degio, who inoculated himself for the plague. He inserted, with a lancet, under the cuticle of the arm, a little of the matter from a pestilential abscess. On the fourth day after inoculation the fever appeared ; he treated himself in all respects in the same way as if he had been inoculated for the small-pox, paying particular attention to the cool regimen. His only medi- cines Avere cold Avater ancl vinegar, with a little wine. The com- plaint proved so mild that he Avas never confined to bed, but Avas generally in the open air. It was not a more severe complaint than the common inoculated small-pox. This surgeon afterwards regularly attended an hospital allotted for the reception of patients under the plague, Avithout feeling any symptom of the disorder ; while most ofthe other surgeons fell a sacrifice to it. From one case hoAveA'er nothing conclusive can be drawn ; besides, it is far from being uncommon for the plague to attack the same person a second or third time. It appears from the foregoing case, that the contagion of plague produces the disease about four days after infection. De Mertens also observes, that the attendants on the sick generally fell ill about the fourth or fifth day, and Dr. Guthrie relates a case in which the patient sickened on the fourth day. Sometimes how- ever its effects are much more sudden. Waldshmidt mentions the case of a person, who while he was drying some Avet clothes which had been worn by a patient under the plague, was imme- diately seized with nausea ancl head-ach, and died on the sixth day, a bubo ancl other pestilential symptoms having made their ap* pearance. Brutes are incapable of receiving this disease, although, like * In pregnant women the plague generally produces abortion 492 PLAGUE. other things which have been in contact with or near the sick, they are often the means of conveying the contagion from one person lo another. It appears however from an instance alluded to in the Introduction, and some similar ones mentioned by Waldshmidt, that the contagion of the plague, if received into the stonmch, often produces violent effects on brutes ; a circum- stance Avhich affords a strong argument against contagion, in ca- sual infection, making its first attack on the stomach. The contagion of the plague, like that of typhus, seems some- times to act merely as a predisposing cause. When speaking of the latter, it was observed that the observations of Dr. Lind have proved the contagion of typhus may sometimes lurk in the body and remain inactive for a considerable length of time, if the patient is not exposed to other causes of the disease, which seem to sub- ject the system to its action. De Mertens makes a similar ob- servation with respect to the plague ; many, he observes, were suddenly seized after a hearty meal, a fit of anger, or violent ex- ercise. It is of great importance to determine how long the contagion of plague will lurk in the human body, or in fomites Avhiie freely exposed to the air, and retain its activity, as this circumstance de- termines the duration of quarantine. Dr. Cullen thinks forty days longer than necessary for the quarantine of people ; and wiih regard to that of goods, he is of opinion that Avere they properly unpacked and aired, the term of their quarantine might also be shortened. " I suggested," Dr. Guthrie observes in his Letter to Dr. Dun- can, " to Earon Ash, physician general to the Russian army, a " doubt of the possibility that the very active contagion of tlie " plague could remain so long lateni in the body, as the quar- " airine of persons seems to imply, and thatit appeared to me " lobe founded on an imperfect knowledge of the disease drawn " from a period of i^uoranc.-. or of general Consternation and " terror. His answer w;-.s, that he did not think that the conta- " gious nature ot this violent disease could remain longer in the " body thru fourteen days without declaring itself on, or before, " that period, Uitth.it from his own observation and experience " he could not take it upon him to s>,j' that it could be con- «< cealed so lo::g. .Such were likewise the answers I received "from the other medical gentlemen whom I consulted on the " •M'ljcct. Soi:*..: gave a little n-ore latitude, ancl *.cme less, as it " can only be a matter of opinion, but none exceeded fourteen " clays." I:: appears fr?ni different f.icts, above alluded to, that the plague genei'cdiy appr m-.s asc rlv v. the i< v til ■;.: fifth day after i.ilcction ; bin we do not '.. <>-.. • ; h ;...;-(». ,;'.u has laboured under tlu cV.i-t..;e h c '. ...1: --..; .-.,, ;-,cr huv. long the con- PLAGUE. 495 tagion may lurk in an unfavourable habit without producing the disease, and may yet be communicated and excite the disease in habits more susceptible of the infection. Upon the whole we have reason to believe, that a quarantine of forty days is conside- rably longer than necessary for persons, and probably for goods al- so. Experience however has not yet determined how much of this term may be abated. It appears from what Avas said aboA'e, that the plague at the commencement of the epidemic is very frequently uncharac- terized by the proper pestilential symptoms ; it has also been ob- served that at this period it is less contagious than at the height of the epidemic ; a circumstance which further contributes towards a deception respecting its real nature. But the most unaccountable circumstance respecting the con- tagion of the plague, and which has also been observed more or less strikingly of the contagion of other fevers, is, that it often suddenly and without any apparent cause ceases to produce the disease. The plague, saysDe Mertens, ceased at one timeoverthe whole Russian empire, after having prevailed at Moscow and oth- er places for a year and an half. " But a greater difficulty," Dr. " Russell observes, than that of all persons not being susceptible " of infection, arises from the cessatitin of the plague at a pe- " riod when the supposed contagious eifluvia preserved in appa- " rel, furniture, and other fomites, at the end of a pestilential " season, must be allowed not only to exist in a much greater " quantity than can be supposed to be at once accidentally impor- " ted by«comnierce, but in a state also of universal dispersion " over the city. The fact, however unaccountable, is unques- tl tionablv certain, the disease seems to be extinguished by some " cause or causes equally unknown as those which concurred to " render it more or less epidemical in its advance and at its " height. In Europe something may be ascribed to the means " employed for the cleansing of houses and goods supposed lia- " ble lo retain the latent seeds of infectiom But at Aleppo, u av here the distemper is left to take its natural course, and few or " no means of purification are employed, it pursues nearly the « same progress in different years. It declines and revises in " certain seasons, and at length, without tlie interference of human ?c aid, ceases entirely." " Ubi pestis nonduin penitus extinc- V.tafuit',*' says Waldshmidt, " hxc sua sponte prxter omnium " expectationem ita cessavit, ut ne vestigium quidem ejus pos- " tea.appnrueiit." Nor was any one infected by another, he adds, although ihe latter still had the pestilential buboes about him, while articles which had been in contact with the sick en- tirely lost the power of communicating the disease. The plague is generally most fatal at the beginning of the epidemic. 494 PLAGUE. It is remarkable that the convalescents from the plague have the venereal appetite unusually strong, a circumstance which of- ten counteracts the endeavours of the magistrate, and tends to spread the distemper. The same thing has been observed res* peering other malignant fevers. It is particularly remarked by Dr. Rush of the late dreadful fever of North America. SECT. IV. Of the Treatment of the Plague. « In the cure of the plague," Dr Cullen justly remarks, « the *< indications are the same as those of fever in general." f therefore refer the reader to what Avas said of the treatment of continued fever, and shall noAv only make a few additional re* marks particularly applicable to the plague. In the first place, of blood-letting in this complaint. It is a remark of Sydenham, that blood should be let if the physician see the patient before any appearance of a bubo. This maxim, although very different from that which seems warranted by ex* perience, is, notwithstanding, the result of observation ; for it is in those cases where buboes do not appear or are delayed to a late period, that the inflammatory symptoms most frequently run high. Many, particularly the Asiatics, make it a rule to let blood in all cases of the plague, if they see the patient at an early period ; and some recommend it as late as the fourth, fifth, sixth, or sev- enth day, and even some European practitioners have gone nearly as far. Dr. Alexander Russell in his Natural History of Aleppo observes, " It seemed to me that very plentiful bleeding at the " first appearance of the disease was of great service." Others Tun to the opposite, but safer extreme, and declare that blood-let- ting is hurtful in all cases of the plague. The proper mode of practice seems to lie between these extremes. The reader will find many declaring that, in the cases of plague which fell under their observation, they could not perceive that a small blood-letting at the commencement did harm. But al- though this were true, is it sufficient to recommend a remedy, that it does no harm ? The truth seems to be, that the general preju- dice has ahvays been in favour of blood-letting, and no physician's experience has been sufficiently extensive to ascertain its hurtful tendency, unless in cases Avhere the injury done by it is very ap- parent, ancl almost constantly follows its employment. But if there are other cases in which blood-letting has never been attended with any sensible advantage, and which nearly PLAGUE. 4SJI resemble the fevers in which it has been found hurtful, we surely have every reason in such cases to believe it improper. It is in vain to ask what advantage is expected from blood-let- ting in these cases ; authors seem to have assumed it as an axiom, that if blood-letting is not evidently hurtful, it must be benefi- cial in this complaint; and all that they seem anxious about is to adduce cases ancl arguments in support of its innocence. Nor can there be any thing more fallacious than the arguments employed lo prove the innocence of this practice. This the reader will readily perceive, if he ask himself, what are the con- sequences of blood-letting to te dreaded in the plague ? what are its consequences Avhen it evidently does harm ? They are, the symptoms indicating a general loss of tone, the pulse sinks, in- stead of the febrile heat a cold damp spreads over the body, which is often the forerunner of death. But these are the unfavourable train of symptoms to be expected in all ♦he more alarming forms of the plague, and in different cases they supervene at different periods. How extensive then must that experience be, which has ascertained that in any one case blood-letting has not hurried on these symptoms, nay has not occasioned them, where they would not otherwise have appeared. Is it from reviewing the result in eight or ten cases, in half of which blood-letting was, and in the other half was not employed, and observing the course of all nearly the same, that the safety of so important a step is to be determined ? Besides, if such observations prove any thing, they prove that blood-letting in the plague does neither good nor harm, and ought therefore to be laid aside as an useless remedy ; a con- clusion very different indeed from the result of our experience in similar cases, and not to be admitted except of blood-lettings so trifling that neither good nor harm could be expected from them, and which do not therefore deserve the name. Many of the Turks indeed employ local instead of general blood-letting, and in the latter they generally draw much less blood than we are ac- customed to do ; a circumstance which has probably contributed much to establish the safety of blood-letting in the plague. " Upon finding the pulse sink so suddenly after bleeding," an. author I have frequently had occasion to mention observes, " I "-was at first inclined to attribute it to that evacuation, and to sus- " pect in less plethoric habits bleeding must prove still more pre- " judicial ; but I afterwards found the low state inseparable " from certain forms of the disease, ancl often could observe no « material difference in its progress in cases where blood-letting " had or had not been omitted." The author in this quotation confesses that the symptoms of debility were those which ho dreaded, and also those to be feared from the remedy he employ- ed, without informing us of any advantage to be expected from jt, to counterbalance the risk. 496 PLAGUE. The more Ave study the observations of the original Avriters, the more reason we shall find for believing, that the employment of blood-letting in the plague is to be regulated by the same maxims as in other idiopathic fevers. " The measures," says Dr. Cullen, " for moderating the violence of reaction, Avhich op- " erate by diminishing the action of the heart and arteiies, have " seldom any place here, except so far as the antiphlogistic regi- " men is generally proper. Some physicians indeed have re- " commended bleeding, and there may occur cases in which " bleeding may be useful ; but for the most part it is unnecessary, " and in many cases hurtful." An opinion has prevailed, as respecting the other exanthemata, that blood-letting is apt to repel the eruption, which it is feared might be attended with bad consequences. Dr. Russell thought that in one case blood-letting had this effect. Direct experience is not sufficiently extensive and accurate to decide the question, Avhether blood-letting, if otherwise indicated, should be delayed when an eruption is expected ; if avc admit of inference from analogy, it is easily answered. We are led from analogy to believe that emetics may often be useful at the commencement of the plague, and they have sometimes been employed with advantage. " Vomiting," Dr. Alexander Russell,* observes, " was also of the utmost conse- " quence at the beginning." " The mode of treatment," says Dr. Guthrie, " which the Russian physicians found the most " successful in the- plague was, beginning with a vomit on the " appearance of the first symptoms, and working it off Avith acid " drinks. If the nausea and bitter taste in the mouth were not " relieved by the first, they gave a second and sometimes a third " and fourth ; nay if the symptoms were very urgent, they gave " two or three in the space of twelve hours, as there is no time " to be lost in this disease ; for they did not find this evacuation " subject to the same objccti'.,:is as brisk purges, which a man •' in the plague is unable to support." Dr. Patrick Russell also approves of emetics at the commencement, although the preju- dice of the Asiatics against them, prevented his employing them at an early period. We have reason to believe, that in the progress of the disease they will seldom be of much service, unless Avhen necessary for evacuating offending matter ; and by their debilitating effects they may do much harm. When retching occurs without vomit- ing, an emetic is often serviceable. When it fails to allay this symptom, opiates generally succeed. There can be no doubt of the propriety of opiates for the pur- pose of allaying restlessness and procuring sleep in all cases * :5£e his Natural History of Aleppo. PLAGUE. 497 where the excitement is not considerable. Dr. Patrick Russell says he never saw them produce coma. From what we observe in similar fevers, we should a priori believe, that much purging would prove pernicious in the plague ; but that gentle laxatives or clysters, sufficient to keep the body regular, would be found indispensible ; and a great part of this inference has been confirmed by experience. Almost all physicians who have practised in the plague agree, that much purging is hurtful ; but I have already had occasion to observe, that costiveness appears to be less pernicious than we should have expected. A spontaneous diarrhoea in the plague is always a dangerous symptom ; on this account, in those places where the disease is frequent, there is the utmost dread of any means which tend to induce this symptom ; and this often proves an obstacle to the exhibition of any laxative or clyster however mild. Suppositories are much used in Eastern countries, but even these are avoided in the plague, so that the patient often remains costive for a long time, ancl it is said without suffering from it. We may say of this, as of blood-letting, that in a complaint the symptoms of which are so varied, it requires much experience to determine the effects of any mode of practice. But Ave have a double reason for drawing our conclusion cautiously, when the measures Avhich appear safe have in similar cases been found per- nicious Besides, although the common inconveniences of cos- tiveness be less felt in this complaint than in many others, it seems often to occasion an accumulation of irritating matter in the intestines, which sometimes induces the very symptom which we are endeavouring to prevent. Clysters or suppositories, as they are less apt to occasion diarrhcea, are preferable to cathartics taken by the mouth. When diarrhoea does occur, whether spontaneously or from the »se of cathartics, it is for the most part readily checked by opiates at the commencement of the disease ; but in the advanced Btages, opiates, astringents, and every other means we can em- piov, often fail to relieve this symptom, and then the prognosis is fatal. " From some principles Avith respect to fever in general," Dr. Cullen observes, " and with respect to the plague in particular. I " am of opinion, that after the exhibition of the first vomit, the " body should be disposed to sweat, which ought to be raised to a " moderate degree only, but continued at least twenty-four hours " or longer, if the patient bears it easily." s. We found in enumerating the symptoms of the plague, that Spontaneous sweating is often attended with the best effects, and Vol. I. P p p 498 PLAGUE. sometimes proves completely critical. There is however in most fevers a Avide difference betAveen the effects of spontaneous sweating and that produced by art, and we have reason to believe that the observations made on this subject, when speaking of con- tinued fever, are applicable to the plague. It has not been determined whether antimonial diaphoretics are useful in the plague. Dr. Russell thinks that, combined with opium, they promise to be serviceable. Little is to be expected from valerian, contrayerva, bezoar, and other similar articles, regarded as diaphoretics, which have been celebrated in this complaint. Nor is much to be expected from camphire, which has also been particularly recommended. A method of promoting sweat, however, very different from those employed in ordinary cases of fever, has lately been attend- ed, it is said, with very great success. It was proposed by Mr. Baldwin, the British agent and consul general at Alexandria, in Egypt, ancl has been made known to the public by a small Treatise in the Italian language by Count Bertcbtold; the following extract from Avhich has been translated into different languages and cir- culated throughout Europe. " The directions are simply these : immediately after a person " is perceived to be infected with the plague he must be taken " into a close room, and over a brazier of hot coals, with a clean " sponge dipped in warm olive oil, his body must be very briskly " rubbed all over, for the purpose of producing a profuse sweat. " During the friction, sugar and juniper berries must be burnt in " the fire, which raise a dense and hot smoke that contributes to " the effect. " The friction ought not to be continued more than four minutes, " and a pint of oil is enough to be used at each time. " In general, the first rubbing is followed by a very copious " perspiration ; but should it fail of this effect, the operation may " be repeated, first wiping the body with a warm dry cloth ; and " in order still farther to promote perspiration, the patient may " take any warm sudorific drink, such as elder-flower tea, &c. " It is not necessary to touch the eyes j ancl other tender parts " of the body may be rubbed more gently. " Every possible precaution must be made use of to prevent " the patient taking cold, such as keeping covered those parts of " the body not directly under the operation ; nor must the linen " be changed till the perspiration has entirely subsided. " The operation should be repeated once a day, until evident " symptoms of recovery begin to appear. If there are already "• tumours on the body, they should be gently ancl more frequently " rubbed, till they appear to be in a state of suppuration,, when " they may be dressed with the usual plaisters. PLAGUE. 499 u The operation ought to be begun on the first appearance of ** the symptoms of the disease; if neglected till the nerves and " the mass of blood are affected, or a diarrhoea has commenced, " little hopes can be entertained of cure ; but still the patient " should not be despaired of, as, by an assiduous application of " the means proposed, some few have recovered even after diar- " rhoea had commenced. « During the first four or five days the patient must observe u a very abstemious diet; the author allows only a small quan- " tity of vermicelli, simply boiled in water. Nor must any thing u be taken for the space of 30 or 40 days, except very light food ; " as, he says, an indigestion in any stage of the disorder might be 11 extremely dangerous. He does not allow the use of wine till « the expiration of forty days. " There is no instance of the person rubbing a patient having " taken the infection. He should previously anoint himself all " over with oil, and must avoid receiving the breath of the infect- " ed person into his mouth and nostrils. The prevention to be " used, in all circumstances, is that of carefully anointing the « body, and living upon light and easily digestible food." Mr. Baldwin observes, that among upwards of a million of people who died of the plague in Upper and Lower Egypt, du- ring the space of four years, he could not discover a single oil- man or dealer in oil. With respect to diet there is nothing to be added to what was said when speaking of continued fever. While the synocha lasts it must be light and diluent, being rendered more stimulant and nourishing in proportion as the fever assumes the form of typhus. At all periods of the complaint acids and acidulous fruits are serviceable, and while the synocha lasts, other refrigerants should be employed. Nitre in particular has been much recom- mended. I may here also refer to the treatment of continued fever, for what was said respecting temperature and ventilation, and like- wise respecting the use of bark, wine, and the other medicines termed tonic. Although it has not been customary to employ the latter medicines very freely in the plague, we have reason to believe that they should be had recourse to, as early as the degree of excitement admits of, and, after the typhus has commenced, employed with the same freedom as in other cases of this fever. Nor is any thing further to be said of the use of blisters and rubefacients. The buboes and carbuncles generally require some treatment, hut this part of the subject belongs to the province of surgery. 699 URTICARIA. CHAP. VI. • Ofthe Urticaria. J. HE Urticaria or Nettle-rash is defined by Dr. Cullen, " Febris amphinierina.* Die secundo rubores maculosi urti- u carum punciui as referentes interdiu fere evanescentes, vespere " cum febre recieuntes, et post paucos dies in squamulas minutis- " simas abeuntes." SECT. I. Ofthe Symptoms ofthe Urticaria. DR. Cullen remarks, that he gives the character ofthe nettle- rash rather from the accounts of others than from his own obser- vation, as iie had seldom seen the disease, and never a single case of it in which it tun the course described in his definition. Sydenham considers it a species of erysipelas, and describes it to be a slight fever, soon followed by an eruption of small pus- tules over the whole body, resembling the appearance produced by the stinging of nettles Vogelf regards it as characteristic: of this eruption that it comes out when the skin is exposed to cold, and disappears when it is kept warm. Small vesicles filled with matter are sometimes formed on the tops of the pustules, or as Ellerf observes, without any matter foiming in' the pustules the cuticle breaks, which gives a rough- ness 10 the parts occupied by the eruption. This eruption is attended with intolerable itching, and when it disappears, scratch- ing is apt to reneAv it. It appears most frequently, Burserius|| and Vogel observe, on the face, neck, and arms Before the appearance of the erup- tion, the former author remarks, an increase of debility and some anxiety are frequently observed. The eruption generally appears after the fever has lasted a few hours, and for the most part relieves it. It is said in tbe definition, thai the eruption generally disappears in the day time, but accor- * The term ami himerina is generally used to express a fever, which returns daily and is alwavs finished within the clay, so that it is a quotidi- an irtermit.ei.t. The eini however has not always been employed in precisely ihe same sense. X Vogel's Prxlect. Acad, de Cog. &c. X De Cog. et Cur. Morb. II Institut Med. Pract. URTICARIA. 501 ding to Burserius it sometimes remains out for two or three days. Such are the symptoms of the urticaria which do not require to be considered at greater length. The complaint is seldom met with,* and is usually so trifling as to require no medical as- sistance. Dr. Heberdent describes an eruption similar to that of the ur- ticaria, which was unattended by fever. Burserius regards the essera of authors as a species of urticaria. It only differs from it in the pustules being generally larger and not itchy. SECT. II. Of the Causes of the Urticaria. LITTLE has been determined concerning the causes of this complaint. We have reason to believe it, like many other erup- tive fevers, connected with the state of the primx viae. Syden- ham observes, thatit occurs at all seasons of the year, and seems often produced by too free an use of thin wines or other similar liquors. Burserius says, he has seen it arise from irritating mat- ter in the stomach, or from the perspiration being checked ; so that it is doubtful whether it be properly arranged among the ex- anthemata, from which it also differs in not being contagious. It however, seldom if ever, appears as a symptomatic affection, and in one species of it at least, that described in Dr. Cullen's de- finition, it is always preceded by fever. SECT. III. Of the Treatment of the Urticaria. WITH regard to the treatment of this complaint, if it arises from impurities of the primae vix, these must be cleared. When this is not the case, it generally requires only a gentle laxative to prevent the irritation of retained fasces ; or it any thing else be ne- cessary, the treatment is the same as in synocha. Vogel says of the essera that the retrocession ofthe eruption is not attended with danger. * Vogel says it is not uncommon about Gottingen. } See the first volume of the Medical Transactions. END OF THE SECOND VOL. OF THE ENGLISH EDITION1. wz 2.70 v. I. ' c)